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SIR RICHARD HAS TAKEN OFF HIS CONSIDERING CAP! AN ANTHROPOLOGICAL CRITIQUE OF THE DISEASE MODEL OF ALCOHOLISM BY MIRANDA BLACK A Thesis Submitted to the Division of So cial Sciences of New Col lege of Florida in partial fulfillment of the requirements for the degree of Bachelor of Arts in Anthropology under the sponsorship of Dr. Erin Dean Sarasota, Florida May, 2013
ii TABLE OF CONTENTS Tab le of Figures iv Acknowledgments v Abstract vi Introduction 1 I. History of Alcohol Use and the Myth Making of the Disease Concept of Alcoholism i. Introduction 7 ii. What is Alcohol? 8 iii. Ancient Regards for Alcohol Consumptio n 9 iv. Alc ohol in United States History 10 v. Myth Making of Deviance and Alcohol Addiction 1 1 vi. Medicalizing Alcoholism in Europe and Early America 12 vii. A Construct Built on Language 14 viii. Conclusions 24 II. Approaches to Studying Alcohol Use and Abuse Introduction 26 Part One: Anthropological Approaches i. Material Culture Identity and the Social World 27 ii. Drinking Cultures 2 9 iii. Drinking Occasions 34 iv. Anthropological Theory on the Object of Addiction 36 v. From Drinking Patterns to Drinking P athologies 37 Part Two: Medical Approaches and the Disease Model i. Rationalization of the Disease Concept 38 ii. Social Deterioration and Cultural Discrepancy in Disease Model Discourse 39 iii. Limits to Epigenetic Explanations for Alcoholism 42 iv. Medical Theor y on the Object of Addicti on 43 Part Three: Medical An thropology and the Disease Model i. Re Contex tualizing a Medical Concept 45 ii. Medicalizing Human Nat ure and Quantifying Culture 46 iii. Functionalism in the Dis ease Theories of Alcoholism 50 iv. Conclusions 52
iii III. Pragmatic Applications and Limitations of Disease Theory of Alcoholism : Cases and Examples Introduction 54 Case 1: Powell v Texas (1968) i. Aspect of Disease Theory Challenged 55 ii. Limitations 60 Case 2: Mission Indians of South California i. Aspect of Disease Theory Challenged 62 ii. Limitations 66 iii. Conclusions 71 IV. Conclusive Analysis i. Metaphor in the Disease Model 73 ii. Medicalizing Alcohol Addiction, Perpetuating Stigma 76 iii. Deviance and Mental Illne ss 77 iv. Questioning the Autonomy of the Disease Theory 79 v. Disease Theory as Self Fulfilling Prophecy 82 vi. Conclusion 84 Works Cited 88
v ACKNOWLEDGMENTS I would like to thank my sponsor Erin Dean for her accompaniment, patience and insights during the writing process I would also like to extend gratitude to Uzi Baram and Susan Marks for participating as members of my Baccalaureate Committee. I w ould also like to thank John Gil let t e for providing his writing skills as a resource for myself and any other thesis student s who have reached out. I would like to thank m y parents, Margo and Seth Black and my sisters Danya and Monica Black, for morally supporting my academic career at New College. I would like to thank the ladies of the Bungalo; Bettina Garofolo, Marissa Herman, Liat Krongrad, and Michelle Wheat for ac companying me on this stressful yet triumphant journey, and in the case of Marissa specifically; for feeling my pain at 2am in I would like to thank the bars, pubs, and nightclubs for which granting me first hand familiarity with drinking patterns in what has seemed like their most culturally diverse and extreme forms. Lastly, I would like to thank Puck; our loyal steed and the cuddliest study comp anion one could ever fathom
vi SIR RICHARD HAS TAKEN OFF HIS CONSIDERING CAP! : AN ANTHROPOLOGICAL CRITIQUE OF THE DISEASE MODEL OF ALCOHOLISM Miranda Black New College of Florida, 2013 ABSTRACT Chronic alcohol addiction is a condition which manifests in social behaviors as well as biological consequences. Excessive drinking has not always been interpreted with the negative connotations which it bears today. Alcohol has ex isted in prehistoric cultures not only as a leisur ely commodity but as a relic of religious medicinal, and soc ial rituals. This thesis concerns the role of alcohol use in the United States, focusing on how it came to be stigmatized and how the cultural phenomenon of medicalizing alcohol addiction alleviated, altered, but also in some ways re invented stigmatizati on of the alcoholic. Through waves of social myth making and with the influence of the medical institution, alcohol addiction began to assume the form of a pathological illness. The metaphor is largely represented by the widely f alcoholism, which concretizes the metaphor via linguistic diagnosis, and promotes legal, social, and cultural repercussions. This thesis explores the making of this metaphor, the anthropological and medical approaches to studying alcohol and alcohol add iction, and the pragmatic limitations of a culturally reductive disease model. ______________________ Dr. Erin Dean Division of Social Sciences
iv LIST OF FIGURES Figure 1: Moral and Physical Thermometer by Benjamin Rush I : vii 17 Figure 2: Model for Predisposition and Development of Alcoholism II: iii 43 Figure 3: Public Intoxication ( Comic ) III : i 55 Figure 4 : Expectations of the Effec ts of Alcohol in Mission Indians III: ii: ii 70
1 Introduction Al cohol, or ethyl alcohol is present in all alcoholic beverages by definition. It is merely a physical substa nce However, alcohol represents a form of material culture 1 when it engages with man and it has variously served as societal me diator, religious transmitter, political instrument or even a s afer alternative to drinking water Consumption is the most primary and direct interaction between man and alcohol. However, c onsumption of alcohol is never merely consumption for it s own sake. It is always consumption for an effect W hen the effect becomes negative, these adverse consequences of alcohol may result in the physical conditi on of chronic alcohol addiction. Alcohol serves as the physical mediator between man and the negative physiological consequences from excessive alcohol consumption. Therefore it becomes viewed metaphorically as the germ which causes physical deterioration to the host if his or her chronic drinking habits take over his or her health and lifestyle Alcoholism becomes classified as a disease in what is a complex civic analogy within the medical sphere and beyond As seen by the mere existence of the disease model of alcoholism, there are contesting beliefs as to what can and cannot be considered a disease. However, this thesis attempts to analyze alcoholism against a working definition of disease, whi ch conforms to the most steadfast axioms of Western medici These are: 1) A disease is an invasive pathology with either genetic or environmental determinants, or a combination of both. 1 specific me aning formulated around a substance beyond its self evident physi cal boundaries (Dietler 2006:231 )
2 2) A disease leaves no room for volition. Once an individual is inflicted with disease, he or she may not escape it merely upon his or her own volition. (There is also an understanding here that, if this kind of escape was possible, the diseased individual would at least attempt this option because it would restore him or her back to health.) 3) A disease either has a possible genetic lineage or (if the disease is not 2 at which the disease is culmin at ed and will inevitably develop. 4) There is a biological cure or treatment for disease, regardless of whether or not it has been developed. There is something concrete necessarily occurring within the disease pathology that could be inhibited, fixed or co untered (given the technology exists). 3 5) A disease stands on its own. It does not require external social factors to determine whether or not it exists, and it does not require diagnostic (linguistic) recognition. A diagnosis of a disease should only ser ve to reflect and organize the components of what already exists on its own, naturally. The disease model of alcoholism is based on the assumptions that alcoholism is an acquired pathological illness with recognizable and diagnosable symptoms. It is thought to consist of both biological and environmental determinants. The disease model assumes a lack of responsibility and control for the actions taken due to the urgent craving a nd consequential loss of willpower and thus directs consequences away from the addict, in the same way an epileptic cannot avoid seizures. It is not my intention to claim that chronic alcoholism does not resemble a disease in some ways, or that the biological factors which have been used to build the disease concept are not true. Rather, I challenge whether the categorical term ( as a disease ) serves any medical or cultural purpose th 2 3 A treatment may be difficult to keep up with diseases such as cancer or HIV AIDS which self replicate or multiply at an exponentially rapid rate, but there are nevertheless measures which may be attempted.
3 simply merely to addiction are those which pass diagnosable dr inking patterns and consequential relationship with alcohol in relation to his or her norms. To include this discrepancy within a single encompassing disease concept for alcoholism is to confuse social deviation with medical symptom atic expression Both alcohol and alcohol addiction when pack aged and labeled as facilitator of social (drinking) norms or a literary disease model ( respectively ) have the power to alter the identity of the individual or the group The epidemiology of the culturally constructed form of the disease of addiction has historically been equated with deviance, psychotic abnormalities, and madness Collective rule making, social judgment, and application of sanctions (penalty) are responses to all types of activities classified as inclu ding alcoholism myth making (Conrad 1992: 6 7). I establish the socially cons tructed analogy between addictive alcohol use and pathological disease. I demonstrate how from socially acceptable drinking patterns, and toward debaucherous, anti social or criminal behaviors. A disease model becomes dressed in language which represents, validates, an d reinforces the metaphor through the language itself (by form), and the fact that it is language for a diagnosis (by function). I hold that this ty pe of human digression cannot (and ought not to ) be feasibly represented very own medical disease theory. The signifiers of disease
4 4 The disease concept of alcoholism, specifically, blends the properties of addiction with properties that are uniquely determined by the fact that it i s alcohol use. While there are other psychoactive dietary or recreational substances which cause bodily deterioration (addiction included), there is no or cocain e ism Whether you refer to alcohol as a dietary substance or as a psychoa c tive agent it can be seen from a multitude of perspectives that culture h as strictly conditioned its use. Equating varying cultural practices such as alcoh ol consumption in designing and prescribing a universal diagnosis for disease, can cause the difference s t o become lost in translation, undermined, or misinterpreted. I view the disease model of alcohol addiction as problematic for several reasons. It is based on unproven science and is more like a metaphor taken too literally; it erroneously re moves a sense of responsibility and consequence from the alcohol addict for his or her actions b ased on a premise that an addiction is a surrender of self control ; and ultimately, claiming alcoholism is a disease does mor e to stigmatize the addict than to defend him /her by constructing him as deviant condition s are an inevitable response to their genetic make up, they can be considered in some ways inferior by nature, and their condition bec omes seemingly more inescapable. Furthermore, the disease model of alcohol addiction fails in its attempts at pragmatic utility. There is no cure or even treatment for alcoholism. Alcoholics Anonymous other voluntary or i nvoluntary means of containment, and pharmaceutical medications 5 allegedly serve as treatments for disease. 4 It is not the intent of this thesis to argue wheth a disease. 5 Disulfiram and Naltrexone are two pharmaceuticals administered for the treatment of alcoholism. Disulfiram causes an adverse reaction when mixed with alcohol, and Naltrexone neurologi cally blocks the
5 However, when these resources do provoke results, it is due to their influences on the mandatory abstinence, or a chemical decrease in the addictive force (respectively). The only means for reducing er cure for alcoholism does not prove it is not a disease, as there are plenty of diseases which cannot be cured. It does, however, limit the potential pragmatic productivity of labelling alcoholism a disease. The first chapter of this thesis begins with a brief overview of what alcohol is and has been as a culturally significant form of embodied material culture in the history of the United States. It discusses the course of the myth making of alcoholism as a disease, and the ways religious beliefs, mora ls, notions of societal deviance, and linguistic determinism have influenced the composite construction of the disease model of alcoholism. The second chapter reviews a breadth of approaches which compose the literature on alcohol, alcohol consumption, an d the disease model. It begins with an overview of anthropological approaches to studying alcohol and patterns of alcohol consumption I follow this section with a brief overview of medical approaches to studying alcohol, and an examination of the incons istencies and potential fallacies which arise from attempts to fully medicalize a cultural phenomenon. Once this argument has been established, I provide cases and examples in which the pragmatic applications of a disease model of alcoholism are challenge d wholly, or are at least limited. I conclude linking the cultural and medical realms of alcohol consumption which I assert is presumptuous unsupported and drinking, and conversely strengthen the volition of the drinker against drinking.
6 generally undeserving of its own all encompassing and (allegedly) autonomous disease model.
7 I. Brief History of Alcohol Use and the Myth Making of the Disease Concept of Alcoholism i Introduction Among the realm of psychoactive substances, alcohol has undergone a career of great irony. Like many of its naturally occurring psychoactive counterparts, its strong, int ox icating properties endowed upon it a promi nent role in antiquity among cultures of all varieties (including and especially where it originates in Middle Eastern areas, where alcohol is today condemned and prohibited, in what is perhaps a great irony within itself). Its effects appeal to hedonistic desires for temporar y phys ical and mental gratification indicative of other pursuits of immortalit y It was validated through its allusions in the Old and New Testament. Alcohol had created societal discourse dedicated to celebrating its effects and ritualizing its consumpt ion in various forms and in various settings. T he great enduring irony is that it continues to be a widely celebrated, licit, commercialized drug, while it has simultaneous ly spurred a discourse dedicated to proclaiming i ts deviance. A discourse of devia nce generally covers the over consumption or mis consumption of alcohol according to societal standards. The same intoxicating effect which g ives alcohol its honorable and enduring recognition in various cultural manifestations is the same thing which demo nizes it. In what cult ural context s is the intoxication from alcohol which has been revered in the religious and leisure activities of even the most noble and admirable of a uthorities also construed as maniacal and dangerous not only to the consumer but to the society within which he drinks?
8 This chapter begins with a clarification of what alcohol technically consists of This is followed by brief discussions of ancient reasons for alcohol consumption and a more recent hist ory of alcohol use in the United States. I then explore the ways in which excessive drinking (often referred to as alcohol addiction or alcoholism ) has been socially constructed a s a disease (even prior to attempts to include medical evidence in suppo rting such a claim). It looks at the trends in ps eudo scientific logic and the propaganda and political actions which elucidate d those logics. ii What is Alcohol? Before discussing and alcohol addiction in context it is useful to acknowledge a c lear definition of what the substance of alcohol actually is As a chemical compound, alcohol has the pharmacological property of altering the nervous Alcohol belongs to a class of chemicals called central nervous system (CNS) depressants, accompanied by such anti anxiety and anesthetic medical drugs as the barbiturates and benzodiazepin es (McNeece and DiNitto 1998:4 ) Alcohol as the word is used socially is not a distinct ly self evident object, but rather a (more recent) culturally specif ic, analytic category lumping together ever ything with ethyl alcohol or ethanol (C2 H5OH) the type of alcohol which can be consumed, as opposed to methyl alcohol which is used as fuel. Alcoholic beverages generally consist of ethyl alcohol, by orings, flavorings, and water (McNeece and DiNitto 1998: 4). E thanol was only discovered during the 20 th Century b ut alcoholic beverages were intentionally created and consumed far earlier (Dietler 2006 : 231). Any type of sugary fluid will ferment when exposed to omnipresent yeast spores (McNeece and
9 DiNitto 1998: 5) Due to its often spontaneous availability, various cultures around the world were able to discover alcohol with no cultural interaction or advanced technologies necessary Upon its consumption, it did not take long to discover its psychoactive properties. Alcohol was accessi ble and convenient and therefore it was incorporated into the diets of almost every known culture. Michael Dietler 1 believes alcohol should be classified as a food with psychoactive tendencies rather than a drug (Dietler 2006: 231) The same grain that makes beer and whiskey can make porridge and bread. A fter all, alcohol must first be consumed before its psychoactive pharmacological properties can take effect. iii Ancient Regards for Alcohol Consumption Traditions of social alcohol consumption have ancient roots. This thesis focus es on the United States, but alcohol has existed and thus acquired certain consumption s most ancient functions were for sacred ritual and medicine, along with regular dietary consumption. Alcoh ol has been utilized as a figurative vessel for spiritual enlightenment, due to its psychoactive properties. Former psychiatrist with the Addiction Research Foundation in Toronto Dr. Andrew Malcolm has claimed facilitatin (Malcolm 1971: 4). As man developed religious syste ms and included m ind altering potions in religious ritual drunkenness and revelry remained in te rwoven with God and worship (Still 1973: 9). Further, in Christianity, the Eucharist exemplifies a ritual in which wine 1 Michael Dietler is an anthropologist from the University of Chicago who specializes in studies of alcohol, food and feasting.
10 drinking took on transformative powers, and the wine drinker himself would transcend the profane to ward the sacred, and could attain immorality. l i nked with the fabled elixir of life 2 ( Still 1973: 10). In Ancient Greece, the concept of altered consci ousness and poisoning. A lcohol was regarded as the substance with the greatest risk for intoxication and addictio n This new attitude was expounded in the ing the house that welcomed him ( Escohotado 1996:2 ). What was beli e ved to nourish man also had the potential to poison him. iv. Alcohol in United States History Alcohol, tobacco, caffeine, and limited forms of opium have been the pillars of leisurely, routinized drug use for European settlers and Native Americans alike since they exchan ged the ir substances (whether peacefull y or otherwise ) upon the colonists arrivals Arabella departed from England for Boston with three times as much beer as water, and approximately ten thousand gallons of wine (Tracy and Acker 2004: 3). Drinking was an essential way of life for Europeans and British in societies where most water sources were polluted (Tracy and Acker 2004: 2). This rationale followed the settlers to the colonies. They made a 2 magic or black magic ), sought by doctors, witches, and laypeople in ancient times.
11 strict distinction between dr i nking and d runkenness; the former was a proud and historic tradition, but the latter was the work of the Devil (Tracy and Acker 2004: 3). Alcohol was immensely profitable for the European colonists, however, and the fear of drunken deviance neve r successfully blunted the capacity of the cultural empire of alcohol and alcohol consumption in the United States. The Prohibition and Tempera n ce movements of the early 19 th Century were unsustainable movements in the face of the much l arger and more powerful forces of alcoho l production, trade, and consumption although they were nevertheless influential in propagating some of the negative connotations of alcohol consumption. Prohibition and its repeal represent an era in which consumption of alcohol weaves in and out of legality. v Myth Making of Deviance and Alcohol Addiction Since alcohol addiction was publicly recognized, it had been likened to madness and deviance, and had assumed some of the same public sentiments as other diseases and psuedo disease conditions considered deviant. Foucault succinctly outlines a genealogy of where madness as it is societally perceived derives from: In the classical period, indigence, laziness, vice, and madness mingled in an equal guilt within unreason; madmen were caught in the great confinement of poverty and unemployment, but all had been promoted, in the proximity of transgressi on, to the essence of a Fall Now madness belonged to social failure which appeared without distinction as its cause, model, and limit. Half a century later, mental disease would b ecome degeneracy Henceforth, the essential madness, and the really dangerous one, was that which rose f rom the lower depths o f society ( Foucault 1961: 440 ) Madness which was attributable to social failure had made the transition to mental disease attributable to degeneracy Alcohol addiction has long been associated with madness, and explanations for mental disease in general shifted blame from social causes
12 to physical and in ternal causes; from culture bound to etiological. Alcohol addiction, like madness had made the leap in the public eye from a matter of social ineptitude to one of inherent, bodi ly inadequacy. Th us, this transition in the public attitude is a step toward the disease metaphor considered by this thesis Alcohol addiction became mythicized l ike witchcraft, l eprosy, epilepsy and degeneracy had been Like these diseases, it too was chronic, and it displayed appalling symptoms in the sufferer. It was even treated as a contagious disease, despite any obvious proof that addiction could spread among individuals (Conrad 1992:49). The myth of deviant addic tion and the social diagnosis thereof is created through the active element s of several societal processes, including notions of deviance, theological moral foundations, medicalization and linguistic labels, co contagion a nd criminal inclina tions, and the regulations and institutions used to funnel the diagnosed addi ct from normal society via legal and spatial confinement The following sections will consider these elements in more detail. v i. Medicalizing Alcoholism in Europe and Early America In ancient societies, diseases were given supernatural explanations in the absence of scientific knowledge, and medicine was left to the priest and shamans. In the 17 th and 18 th Centuries in Europe and America excessive alcoh ol consumption was treated Neither a uthorities nor laypeople seemed to have a problem with alcohol itself, inherently. When they did, the blame was put only on the act of dr inking and the drin ker committing it. Excessive drinking was only primarily opposed by an elite minority of scholars and church leaders.
13 It was considered an abuse of God's gift, and was sometimes attributed to the work of the Devil. Drunks were suspended or, eventually, excommunicated from the Church. Because of the Church's prominent voice alongside civil authorities, this theological perspective was recognized, accepted, and mimicked in the form of "public degradation, fines, ostracism, whippings, and i mprisonment" ( Lender 1973 : 353 ). The Puritan clergy became the alleged spec ialists on "habitual" drinking. T he Puritans had a lengthy tradition of labeling certain behaviors as deviant according to the moral standards of their society (most infamously the Salem Witch Trials) The higher status members in society feared the spectre o and developed a means for institutionally punishing those whom (Conrad 1992: 7). Applying a notion of deviance to consuming alcohol was precarious for the Puritan clergymen, due to their own leisurely taste for the drink and the perennial status drinking had earned itself in society throughout the 17 th and 18 th Centuries. In fact, churches and drinking houses were often situated close to each other both as socia l centers of the community (Conrad 1992: 75 ). It was therefore necessary to distinguish the good and godly from the deviant, while partaking in the same activity ( drinking ). S disease first emerged in the final decades of 18 th Century United States and England to fulfill this purpose (Conrad 1992:78)
14 vi i. A Const ruct Built on Language An essential instrument in the myth making of addiction and other deviant behaviors is the language chosen to depict it. It was not even until the 18 th Century that And since emerging theories of alcoholism were medically unprovable language was the only tool available to demonstrate and provide the structures o f these th eories Langu age served to implicate the divisions betwee n right and wrong; good and bad; and normal and diseased drinking. Such language, when pieced together for diagnosis, was meant to corroborate the same kind of dichotomous, good or bad, healthy or sick status of the drinker. The discovery of addictive abnormal drinking in specific opposition to normal 2004: 33). Linguistic distinctions have helped sustain the logic that bad people (defined as people different from us) use drugs because of their inherent badness, whereas good people (people like us) use drugs because some evil force outside themselves overpowered their goodness. Our labels help distinguish between good and ba d drugs and between good people who deserve our sympathy and professional assistance and bad people who s hould be isolated and punished (White 2004: 48). Prescriptive linguistic labels also helped sort out whether one ought to sympathize or be Pennsylvania Gazette in 1737, in which he defin ed 235 terms to describe drinking, drink ers, and intoxication He attests to the sheer magnitude of terms used by drinkers, for drinkers, in his introduction to the treatise. much frequented Taverns would imagine the number of them so great as it really is
15 (Larson 1937:90 ). For the drinking literatur e of its kind s offers a unique perspective in categorizing the chronic drinker. He p roduces his list by using the own territory, the tavern, as a field site. Franklin exhibited an ethnographic method of compounding a list of drinker terminology, withi n which he provides terms which exist among drinkers, rather than terms designed externally to b e projected upon drinkers based on medically or empirically hypothesized conviction. 3 However, it was etic in some respect, as it did have an agenda; to promote temperance in the colonies by ridiculing drunkenness shop patrons and tavern habitus who would resort to almost any expression rather than 87). treatise exemplified a burgeoning trend in linguistically tagging addiction and categorizing those involved. Some expressions include: Sir Richard has taken off his considering cap! His treatise was largely influenced by terms he overheard of drinkers speaking a bout drunks, and thus is more a reflection of his society rather than an official doctrine for drunkenness The sheer quantity of terms in his piece alone represents an overcompensation for hi s the drunks. Scottish physician Thomas Trotter and American physician Benjamin Rush were key figures in defining alcoholism in medical (and social) terms in the late 18 th Century and early 19 th Century They were conte mporaries who partook in the similar task of medicalizing alcoholism with the attribution of a disease concept, but the differences in 3 approach, usually both etic and emic.
16 their ideas repres ent major differences in theories of the roots of the disease (for those who at the very least agreed it was a disease). while Rush saw drunkenness as a disease in which alcohol was the causal agent, with loss of control over drinking behavior as the characteristic symptom. He believed t otal abstinence was the only effective cure (Edwards 2003:4 ). The lack of concrete scientific evidence provin g the roots of addiction enabled both theories to exist one which pointed to alcohol and another which pointed at the state of intoxication as the addictive force driving alcoholism. This dichotomy will in further de tail in Chapter II
17 Figure 1 : Benjamin Rush Moral and Physical Thermometer from An Inquiry into the Effects of Ardent Spirits upon the Human Body and Mind, with an Account of the Means of Preventing and of the Remedies for Curing Them (1823).
18 In hi s treatise An Inquiry into the Effects of Ardent Spirits upon the Human Body and Mind, with an Account of the Means of Preventing and of the Remedies for Curing Them 4 (Figure 1) Benjamin Rush claimed the ways to prevent recurrent fits of drunkenness and d estroy the desire for ardent spirits were religious, metaphysical, and medical. Regarding t he first he declares their desire for ardent spirits, by a practical belief in the doct rines of the Christian (Rush 1823:31). accompanying explanation and personal anecdotes). He not only refers to excessive what it is to be properly referred to as b y all, by principle of coining a universal diagnosis With his terminological and ideological choices, he was instructing his audience to bridge the moral and medical perceptions of addiction, as if both were aligned in their official objectivity. The fi rst two symptoms he lists for someone stricken with the disease (Rush 1823:5) These signs of disease confirms a sociological char acteristic of a relative nature in relation to a societally established n ormal level of the opposing (but mutually problematic) garrulity and silence. Rush also attempted to rationalize his notions of the disease of drunkenness applying newly popularized medica l models of the time. He claimed drunkenness is heredita ry and contagious. He validated these scientific assertions by conflating drunkenness with other hereditary and contagious diseases he felt it resembled Rush presumptuously affiliated the fact that alcohol dependence seemed to span familial 4 0. I reference a later edition of the original text re printed in 1823 b y James Loring.
19 generations with the fact that hereditary diseases also carry on through generations (Rush 1823: 8) His assumption that drunkenness must thus be hereditary is ov erly conclusive. Rush revolutionar il y altered the paradigmatic view that addicts were merely insane individuals by attributing addi ction to non accusatory disease. However, his ideas did not entirely sever the habit from its association with madn ess. Rush listed a nother indicating sign of the odious disease as indicate a temporary fit of madness 1823: 7 ). In explaining his conviction, Rush referenced expiated by the crim es he committed while living, animates brute animals, which then die and bring their criminal, brute, and animalistic vices into the soul of a living man. In its wh ich serves to explain the derivations of human vice. However, Rush went on to claim es during fits of drunkenness, despite the fact that Pythagoras does not mention drunke nness resemble a calf in stupidity, an ass in roaring, a mad bull in quarreling and fighting, a dog in cruelty, a tiger in fetor, a skunk in filthiness, a hog, and in obscenity a he 1823: 7 1823: 5). on the other hand, was used to describe what would today be considered addiction or chemical dependency (White 2004: 35), but in more indirect and abstract terms than simply having an inclination for alcohol itself. In 1894,
20 prominent 19 th C entury addiction expert Norman Kerr defined inebriety as a constitutional disease of the nervous system. He believed the focal point of the compulsion to drink or use drugs was an insatiable desire for the state of intoxication, rather than the intoxicating agen t. He thus preferred (and popularized) the uses of the (White 2004:36) In the 19 th enthusiasm with curing and treating addiction for alcohol and opium. There was a proliferation of addiction experts, institutions, books and journals, as the field of addiction expertise became professionally ). Addiction sanitaria, private ho spitals, and international inebriety conferences worked together in high profile with the Temperance movement. Alcohol addiction was commoditized and therefore the appeal of medicalizing alcoholism grew correspondingly. The i nebriety movement ended as quickly as it began. The Quarterly Journal of Inebriety ceased publication in 1914 and A merican A ssociation for the C ure of I nebriates (which was developed in 1870) disbanded in 1920 (Aurin 2000:425) The alleged underlying cause of this was dem ographic shift among the addicted from upper middle to lower class, who were considered unattractive as medical clients (Courtwright 2001 : 422 ) In 1819, Christopher Wilhelm Hufeland introduced the term dipsomania Inebriism: Pathological and Psychological Study encompassing term for the fated
21 identities of these people. Dipsomania was considered a special form of temporary insani ty (White 2004:35). Dipsomaniacs were only characterized as insane when desperately pursuing intoxication through alcohol (which is then secondarily characterized by the action of binge drinking). Although the term labeled this type of drinker with only part time stigmatization, it was common for non alcoholics to view the time identifier of inferiority. The wealthy tended to be diagnosed with a dipsomania, upon which the y had fallen victim and their excessive drinking behaviors were pardoned as such. The poor, however, were suffering from the vice of willful drunkenness. It was (or is) not uncommon to see the disease concept used as part of social agenda (White 2004:49) Despite being typically diagnosed as such, the affluent in society still adapted slang terms the negative seeming qualities of the term, elites were distancing themselves from the stigmatic properties of the diagnostic term: those which seemed to imply the inherent and dehumanizing aspects of being sick with dipsomania. These qualities, they felt were reserved for lower class individuals with the same diagnosis from whom they needed to be distanced. first attempt to associate so called habitual drinking with an inclination towards alcohol specifically, however, it took almost a century to become popular, and intemperance, barrel fever, habitual drunkenness, dipsomania, inebriety or ebriosity, victim of drink,
22 and liquor habit dominated cultural and prof essional discourse instead throughout the late 19 th and early 20 th Centuries (White 2004:36) Around a century after Huss coined his term, which was exclusive to the term for an individual addicted to alcohol. Following the repeal of Prohibition in 1933, however, the term inebriety fell out of favor because it encompassed drugs that were both culturally good and to be celebrated, as well as culturally bad and to be increasingly demonized (White 2004:35). had grouped the pursuit of intoxication in general, so the all encompassing term 5 established as a popular term, chronic drinking had long since been considered a disease. A disease necessitates a diagnosis, assuring that the individual is or is not in fact experiencing the disease, on a dichotomous basis. The absolutism required for chroni c drinking to be a disease cast a generalizing shadow over all individuals who may have be en experiencing the problems a ssociated with drinking, but were not classifiable as alcoholics. of alcoholism and was among the first to systematically arrange the symptoms of alcohol addiction modeled after medical disease. In the 1940s, h e published a study of the "phases of alcoholism" in which he hypothesized an inevitable sequence of increasingly uncontrolled drinking progressively leading to such symptoms as blackouts, tolerance, withdrawal distress, 5 utical companies to sell some of these drugs, particularly opiates (White 2004:40).
23 insanity and death (Hanson 1997 201 3) 6 Jellinek rejected the notion of a single clinical diagnosis for alcoholism and distinguished fourteen types of abnormal drinkers, in an attempt to clarify and specify not only differing conditions of alcohol addiction but also to distinguish which we re and were not to be considered disease. He defined as diseases ). Charles Durfee preferred the terms problem drinking/drinker on the grounds that alco hol was a problem for people that were not diagnosable as alcoholics. In 1942, Durfee found support in Dwight Anderson who added malady or ailment instead of disease with conditions with a physical rather th an an emotional basis. Anderson believed alcoholism was a sickness rather than disea se, ( White 2004 : 36 ). The over extension of a term meant to define addiction as a medical diagnosis was thought to dilute its clinical utility. In 1949 Sheldon Bacon expressed concern about whose drinking was problematic in the community as diagnosable alcoholics, though the y were considered unfit for treatment drinkers who were feebleminded, psychotic, or had personality disorders. Bacon suggested t stigmat izing enough for their actual condition, which he termed misfit drinking (White 2004:37). This move implied social prerequisites for being termed an 6 Jellinek recognized the scientific inadequacy of his idea, but saw it as a starting point for research. However, it was soon accepted as proven fact by many people. Iro nically, Jellinek came to recognize the inadequacies of his hypothesis and later distanced himself from it (Hanson 1997 2013).
24 their social inep t ness through a masking, less socially disfiguring disease diagnosis. It would also allow them access to treatment. The World Health Organization agreed that over appli cation of diagnosable proposed use of the term which language used could encapsulate addiction to a lcohol, opiates, cocaine, and other drugs alike. By the middle of the 20th C entury, the r ise of Alcoholics Anonymous (also popularly referred to as AA or Al Anon) the publications of E. M. Jellinek, and the establishment of the Yale Center for Alcohol S tudies revived interest in ex ploring the nature of medical and marketable alcoholism The early 1960s saw a flourishing popularity of the idea that, for certain "vulnerable" people, alcohol use leads to physical addiction true disease (White 2004:45) viii Conclusions To reiterate the irony referred to at the beginning of this chapter alcohol has simultaneously earned itself righteous place within evolving European and American societies, as well as its own demonizing discourse. Cultural responses to alc ohol have made an unequivocal contribution to society, regardless of whether they cast a positive or negative light on the drink and the drinker. It was undesirable to blame alcohol entirely because it has been morally justified societally revered, an d profitable each in certain
25 contexts since ancient times The medicalizing of alcohol addiction enabled the shift of blame from the substance to the consumer. This way, the sanctity of alcohol could be protected, and the individual ostracized instead. To routinely drink alcohol to a point of excess was to misuse the social and uncoordinated behaviors when intoxicate d both resembled a compromise of his sanity, self control, and normal social functioning. He was viewed as deviant and mad due to his possession by addiction and the intoxicated mindstate Medicalizing alcohol addiction translated his social ineptness in to pathological illness, yet the types of demonizing ling uistic classifications being coined still sought to stigmatize the alcohol addict for hi s own i llness. Thus, there was still a strong social influence in the process of medicalizing alcohol addiction. The infiltra tion of biases and agendas in the early constructions of the disease model kept it from being objective which, at the very least, can be suppor ted by the sheer quantity of phases through which linguistic categorizations passed. However, by principle a medical condition asserts itself to be objective. Therefore, the social elements which have worked themselves into the construction of the diseas e model have become disg (as opposed to drunkenness) is a disease (rather than a vice) says more about ourselves and our social consciousness that it does about the science 2004:47).
26 II. Approaches to Studying Alcohol Use and Abuse i. Introduction As Chapter I establishes there has been an assortment of theories about alcoholism. The theory currently held as default is the disease model. Its basic tenets are that alcoholism is a disease with recognizable symptoms, causes, and methods of treatment. Although this consensus most largely represents the discourse of alcoholism today, there is a generous breadth of approaches to studying alcohol. The at tempt to approach the field of alcohol and alcohol consump tion from an academic perspective has been relatively monopolized by medical biology, public health, and social psychology. The objectives of these disciplines favored explicating alcohol consumption in terms of individual p athology or social problems (Dietler 2006). Anthropology, however, has viewed this alcohol as pathology literature as ethnocentric m oralizing theory (Dietler 2006: 230). Medical literature is objective and prescri ptive by nature. I n studying a cultural practice such as drinking it focus es not on the culturally significant interaction of alcohol and man but rather on the medically relevant physiological effects which occur due to the interaction of alcohol and the human body Addiction is a relevant to pic w ithin the medical field. As with many medical conditions, there are socio cultural factors which cushion the onset and outcomes of addiction, but these issues are best dealt with by sociology and anthropology. However, the disease model of alcoholism encapsulates the addiction to alcohol as well as socio cultural factors within a single, universal diagnosable disease. This chapter seeks to explore both the anthropological and medical approaches to studying alc ohol and alcohol addiction. I t delves in to some of the issues of
27 translating cultural deviation into medical symptom, including the potential it produces for stigmatization. Part One: Anthropological Approaches to Alcohol Alternative approaches to the medical disease model of alcoholism arose when the demands for and functions of alcohol research expanded to include non medical I n the 1960s, academia began to incorporate cognizance of ing practices, and in doing so, began to accept alcohol as a social artifact and a c ulturally valued good (Dietler 2006 :231 ). In the 1 980s, the medical alcohol and addiction literature was beginning to be more aggressively challenged by anthropo logical engagement on the topic via ethnographic res earch specifically focused on alcohol, rather than simply reporting on it as a secondary byproduct of studies which had been designed for other goals (Dietler 2006). 1 Social historians, anthropologists, and archaeologists have assisted in challenging previous modes of alcohol research by coloring in a cultural historicization of drinking including through an archaeological interest in f easting and other ancient drinking practices emblematizing alcohol as traceable material culture (Dietler 2006: 232 ). ii. Material Culture Identity and the Social World A lcohol has a rather unique relationship with individual and group identity. Alcohol is a special form of embodied material culture, because its relationship (as an artifact) with the social realm destruction through 1 Dietler specifically referenc es the predecessor of his piece, the first of such overviews of anthropological trends of alcohol research: Heath 1987
28 consumption (Dietler 2006: 232 ) The individual experiences physical changes as a result of the alcohol entering the bloodst ream brain chemistry upon intoxication. The person is also participating in the acculturated act of drinking, and his or her dr inking may be jud ged against the conformity of his or he r drinking context. cultural influence can best be examined through the social rules and patterns regarding it. Such rules and patterns, once invented are meant to be adapted to individually (if social normalcy is the goal), and are thus diffused into social arenas as cultural product in various ways. 2 construction of the social world, both in the sense of creating an ideal imag ined world of that imagined world, or 235). Drinking exists within a socially constructed context that binds social acceptability, t radition, and cognitive participation among those involved. th Alcohol serves as the vessel for cultural implementation. Bu t it is not just types of alcohol which serve as indexical signs of identity it is the act of drinking as a learn ed technique du corps in the sense of Mauss (1934 ) 3 Qualitative differences such as drinking paraphernalia, styles of drinking, and 2 This statement is modeled after theory that culture happens through 1958:306). 3 Technique du corps refers to the manner in which the individual learns to use his body in traditional ways (Mauss 1934:3).
29 the cultural capital derived from embodied knowledge about proper consumption practices are all relevant in discerning collective identity and deviation (Dietler 2006:236). The social rules which govern drinking practices act as the interface between mate rial substance and culturally significant, identity generating material culture as substance is material culture isolated from its social meanings and functions It then follows, that rules and qualifiers surrounding drinkers and drinking practices can b e communal identity for those drinking together or sharing tastes and a sense of 2006 : 236). iii. Drinking Cultures Some anthropologists have expressed reluctance toward identifying drinking cultures in favor of studying drinking as the acceptable, predictable, and normative behavior isolated within (but also from) the cultural context in which it is observe d. According to anthropologist Thomas Wilson, anthropology is thought to have moved past as objects of study to considering culture in practice, process and narrative. The re has therefore been a shift away from defining around the groupings of people who identify with a specific drinking culture In anthropology there has been a argues, however, that many (if not most) people in the world use th eir notion of community daily as an expression of their own group solidarity and personal and group identities (Wilson 2005: 9).
30 Wilson intention practice, as a distinction, as an ideology, and as a conception of individual an d group 10). Wilson recognizes that lumping drinking beha viors with their own ideologies as a means for conceptualizin g individual and group identity may become a point of divergence for anthropologists sifting through cultural dimensions of drinking. He admits his approach may be less agreeable to anthropologists and other ethnographers who in the past have f ocused on alcohol and drinking as the normative behaviors displayed in their own cultural contex ts and who avoid es tablishing drinking altogether (Wilson 2005: 10 ). Wilson views his approach to be more agreeable to anthropologists interested in theorizing identity and culture in local, transnational, global, and supra national contexts ( Wilson 2005: 10). Wilson compartmentalizes the facets of form of expression. For example, i for example, he evaluates the role drinking plays in establishing national ion of food memories we are what we ate (Wilson 2005:13) by 2005:16). people who perceive that their distinctive regional behaviors and values are at the core of what can (or should) be seen as a nation.
31 Wilson uses as an example the intricate mix of consumption and expression in the complex relationships among food, drink, and music in the creation of the Yucatecan soul. This mix, he claims, enables the distinctive nature of a Yucatecan identity as part of a regional ide ntity a nd political movement to take shape. Food and alcohol became means for manifesting a long standing ambivalence in the Yucatecan community toward the central government. After Independence from Spain in the early 19 th Century, the Yucatan peninsula and Mexico began to establish the terms for their relationship. Some Yucatecans were willing to join Mexico under certain conditions of guaranteed autonomy, while others remained resistant. The Mexican government repossessed Yucatan after each of three (unsu ccessful) declarations for independence by Yucatecan politicians during the 19 th Century (Wilson 2005:157) Following this conflict, the Yucatecans sought to retain their national identity all the more vehemently as they were faced with coerced annexation and immediate marginalization of their people. Drinking preferences (although individually experienced ) took on a localized homogeneity, representing the encasement of a collective cultural preference. Yucatecan local preferences include cold beer, iced rum, and brandy cocktails (Wilson 2005:158) This cultural preference was not only uniquely their own, but it was distinctly not Mexican. The Yucatecans avoided the trend of importing and appropriating tequila, 4 despite its burgeoning popularity globall y and its He admits, that the Yucatecans are gradually developing a taste for tequila, but that it is not chosen for soc ial interaction 4 Tequila is distinctly a Mexican drink because real tequila only comes from Tequila, Mexico.
32 (Wilson 2005:158). There is an element of communal pride and protection which may be jeopardized upon principle if tequila were to become a presence in the Yucatecan social sphere. E ven more fundamentally important than what the Yucatecans drink is the fact that they drank it, collectively, then and now, and that it helped them to retain a national identity when it was threatened by the Mexican state. the Yucatn and the Mexican state, drinking is one of the motifs in the Yucatecan construction of who they are and who they were, in a projection of their authentic history, Wilson had chosen this particular case to demonstrate his claim that leisure activiti es are very often seen by people to be the embodiment of who they are as individuals and societies, constitutive of ethnicities and national identities. Functionally, W i lson views the act of drinking as the act of identification, differentiation, integrati on, and projection of homogeneity and heterogeneity, particularly in social arenas of ethnicity and national identity (Wilson 2005 :11 ). The Yucatecan example demonstrates the role drinking can assume in constructing national identity. However, drinking c an also construct identity in a smaller spatial and temporal frame. sites where drinking takes place, the locales of regular and celebrated drinking, are places where meanings are made, shared, disputed and reproduce, where identities take shape, flo 10). In this theoretical orientation, a ltering contexts of consumption means altering cultural meaning of drinking. For example, e xcessive drinking is the vice which may
33 be labeled as deviance or disease as discussed in imminent sections. However, in culturally appropriate contexts, excessive drinking has been associate d with celebration and wealth. David Pittman outlines four cultural p ositions w hich he believes can describe attitudes towards drinking by culture. Although exceptions are bound to occur, his four cultural positions are meant to represent the dominant outlooks on drinking by a group at large. He classifies these attitudes conflicting co alcohol ingestion but is negative to ward drunkenness and other drinking pathologies; and the Permissive drinking, drinking behaviors while intoxicated, and drinking pathologies. 5 According to Pittman, American society is the prototype of the am bivalent culture. In American s ociety, drinking pathologies are perpet uated by cultural attitudes which veer conversely toward asceticism and hedonism. society limits the development of stable attitudes toward drinking, and that it restricts the meaning of drinking to one of hedonism and insulates drinking practices from social controls (Myerson 1940: 15). He theorized that drinking thus becomes an uncontrolled and extreme behavior for ma study, in which he found more alcoholic complications in groups with abstinent 5 While defining this category, Pittman disclaims that this type do es not occur as (nearly) homogenously in societies. It appears in certain non literate societies, in cultures undergoing considerable social change, and those in which there are strong economic interests vested in the production and distributi on of alcoholic beverages (Pittman 1967: 4).
34 drinking and inebriety tends to i dentify the act of drinking with personal and social disorganizations. Thus, it inadvertently suggests an inebriety pattern for drinking and kolnick 1958: 460). iv. Drinking Occasions There are various ways heavy drinking can be established as a justifiable or even an endorsed activity in society Feast in g (which is culturally celebrated glorification of excess drinking) is one such event in history Feasting was an intentional and socially accepted tradition whi ch was mainly enjoyed by the upper class Feasting was a particularly important presence in societies with formal centralized leadership roles due client relationship (Dietler 2006:237). Host ing drinking feasts was essential for climbing the social hierarchy by acquiring formal titles or ritual positions, and often became competitive (Dietler 2006:237). 6 Feasti ng was an intentional and coordinated as a ritual occasion and thus the excessive drinking was circumscribed within intentional temp oral bounds. The tradition of feasting sourced from a pre hops time period, before distillation techniques were invented for preserving alcohol, so mass amounts had to be consumed at once (Dietler 2006: 237 ). Dwight Heath demonstrates that social rules can dictate appropriate drinking patter ns based on a temporal frame or when peop le drink. He treats alcohol in the 6 Although feasting in some traditional form may exist in any society, Michael Dietler mentions the particular importance that alcohol in this type of political role has held in cases of petty chiefs and royalty in Africa, and in the Inca imperial state (Di etler 2006:237).
35 context of its function of being consumed in a social setting. Thus he refers to the of eating and living (Heath 2000: 13). Gusfield (1987) describes the transition rite in the U.S. of individuals either pace and expec in the late afternoon, when the nine to five workday comes to an end (Heath 2000:15). Heath acknowledges the the morning hours. 7 He then provides exceptions that have been institutionalized and accepted in more modern times which escap e the threshold of the general rule. For example, the som ewhat recent phenomenon of brunch often includes spirits mixed with Mary) insulate people from having to articulate the fact that they are taking alcohol at what would, norm ally, for them be an i 13). Consumers are of course aware of the presence of ethanol in their breakfast drink, they simply do not wish to pro nounce it, Heath postulates In the United States, like much of the urban industrial ized Western world, midday is a momentous boundary marker between times during which drinking would be inappropriate or permissible. routinely have one or more drinks with their noonday meal. In the late 1970s, U.S. newly wealthy and power 13). Drinking during a work 7 He ath does not focus on explaining or justifying this claim it is accepted in his argument as observable fact.
36 lunch can grease the gears for constructive talking and dealing a mong cosmopo litan colleagues (Heath 2000: 14). In the process, an instance of drinking which would otherwise be frowned upon conversely becomes a self commending indicator of success (but only for a class which was elite to begin with). Their ability to s upersede generally volumes about the specific context within which the exceptions are accepted, and the underlying forces (class, elitist wealth celebration, trend) behind these exceptions suggest conditions of pri vilege can shift and evade what would typically be stigmatic. People with more schooling and higher incomes are generally considered to belong to a higher class status, and this is precisely the demographic which were evading the general rule, according t o Heath. i v. Anthropological Theory on the Object of Addiction Wild Hunger: The Primal Roots of Modern Addiction discusses the primal needs of humans as the key to identifying the most fundamental explanation of addiction nextinguishable primal desire for the substance of their addiction (Wilshire 1998). He suspects we are still driven by the same hunger for primal excitement, but this hunger has become suppressed and confused by modern overlayings of agriculture, industry electronics and technology. had with regenerative source, with wild Nature over the ages kinship with plants and animals, with rocks, trees and horizons. Even terror is a bond with what the swelling presence of things. Addictions try to fill the emptiness left by the loss of ecstatic kinship. They are substitute gratifications that ca nnot last for long slavishly repeated attempt s to keep the emptiness at bay (Wilshire 1998:x xi).
37 He concludes this thought with a final irony xi). Drunkenness, Wilshire attests, is both a semblance and a counterfeit of the 1998:vi). His hopes in exploring this aspect of addiction is to present this feeling relative to un iversal feelings which even non addicts can relate as in basic and primal needs human have to eat, sleep, and attain a primal bond to a metaphysical (and yet natural) regenerative source. v. From Dr inking Patterns to Drinking Pathologies A nthropologists believe cultural context is necessary to consider before researchers can even attempt to understand or explain pathological drinking. David Pittman writes: one to specify those drinking occasions and situations which fall within a beginning of a drinking pathology. Moreover, one must constantly ask how drinking practices relate to other inst itutional structures within the culture, such as religion, econom 4). By outlining the behavior, the discrepanc y (or deviation) between the two is delineated. These devi ations are necessary to establish olism 8 (Pittman 1967: 4). 8 that it results in noti ceable mental disturbance, or in an interference with their bodily and mental health,
38 Part Two: Medical Approaches and the Disease Model i Rationalization of the Disease Concept devi ation from drinking habits with in a theory that is concrete and has boundaries when def ined in a medical context The disease model of alcoholism is characterized by symptoms including impaired control over alcohol, compulsive thoughts about alcohol, and distorted thinking The disease of alcoholism is also believed to include a phy sical dependence due to excessive consumption. As a disease, it is believed to incorporate risk factors, possible predispositions of certain phenotypes, and can be portrayed through both etiology 9 and epidemiology. 10 It is somewhat contradictory that cultural variables sho uld be included in this mo del. The danger of phrasing these cultural factors medically is that the y become trapped w ithin a medical model and there i s an implication that the cultural differences are translatable as sickness, and connected with the ( actually objective and disease like) biological consequences of addiction In a 1992 article from The Journal of the American Medical Association ( JAMA ) the Joint Committee of the National Council on Alcoholism and Drug Dependence, Inc (NCADD) and the American Society of Addiction Medicine (ASAM) published this definition for alcoholism: their interpersonal relations, their smooth social and economic functioning or those who show the 9 Again, 10 disease demographically and with detection of the source and causes of epidemics of infectious diseases.
39 environmental factors influencing its development and manifestations. The disease is often prog ressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, mostly denial. Each of these symptoms (Morse and Flavin 1992:1013). drug intoxicated are all viewed as symptoms of a medical disease. According to Jellinek a disease is ession agrees to call a d isease (McNeece 1998:4 ). Doctors do not actually agree as homogenously as the general level of acceptance for the disease model might imply (Hanson 1997 2013 ) Despite being couched in the language of science, the reemergence of the disease concept of alcoholism was not a result of new scientific findings. Jellinek believed it was necessary to see alcoholism as a disease in order to increase the availability of services for alcoholics within established medical facilities. He also recognized that effort s to prevent alcoholism would still have to address the complex cultural, demographic, political and economic issues contributing to the problem. i i Social Deterioration and Cultural Discrepancy in Disease Model Discourse The disease model is materialized through official diagnostic literature and is sometimes used to represent individual and group identities authoritatively and prescriptively within that literature. This action can be problematic. The most commonly accepted diagnostic literat ure from which the disease model of alcoholism is cited is t he
40 I nternational C lassification of D iseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM) 11 The DSM, whi le most commonly accepted, is also criticized from various angles and fields even from within the medical field itself One such critical standpoint is held by Dr. H erbert Fingarette who has summarized the assertions upheld by the disease model theory: 1) Heavy problem drinkers show a single distinctive pattern of ever greater alcohol use leading to ever greater bodily, mental, and social deterioration. 2) The condition once it appears, persists involuntarily: the craving is irresistible and the drinking is uncontrollable once it has begun. 3) Medical expertise is needed to understand and relieve the condition ('cure the disease') or at least ameliorate its symptoms. 4) Alcoholics are no more responsible legally or morally for their drinking an d its consequences than epileptics are responsible for the consequences of their movements during seizures. ( Fingarette 1990 :49 ). As pe r the first point : the qualification of alcoholism as a disease must rest upon notions of social deterioration. The conf lated concept that a medical condition can be measured in part by social deterioration is evidence of the conflation of cultural actions with path ol ogical illness The statement does also acknowledge bodily and mental deterioration, as a disease would ind uce on the body. s definition of alcoholism is behavioral disorder manifested by repeated drinking of alcoholic beverages in excess of the dietary and social uses of the community and to the extent that it interferes with the social or economic functioning cNeece 1998: 5). An 11 The first of five DSM manuals was published in 1952 within which alcoholism was described as a disease. This was f our years before the American Medical Association declared a lcohol addiction a disease cite one another), they came out with different variations of the disease model and worked along different timelines.
41 individua great enough concern to address its own qualifying symptom within the diagnosis of alcoholism. economic pr oductivity as well as their w 2004: 5). Due to his his capitalist society. His ability to work was compromised, and in a society which measure s his value based on economic productivity he was considered tainted and crippled by his condition. A disease model of alcoholism turns this tainting and crippling into symptoms of disease. Opponents of the disease theory of alcoholism argue that even when a diagnostic criteria set is accepted across different cultures, it does not necessarily indicate that the Wi diger and Sankis 2000:380 ). Further, although universal diseases may certainly be deciphered differently in different cultures, some diseases are considered strictly culture bound syndromes. The American Psychiatric Association states the following (APA 2000:898): The term culture bound syndrome denotes recurrent, locality specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM IV diagnostic category. Many of these patterns are indigenously conside red to be "illnesses," or at least afflictions, and most have local names. Although presentations conforming to the major DSM IV categories can be found throughout the world, the particular symptoms, course, and social response are very often influenced by local cultural factors. In contrast, culture bound syndromes are generally limited to specific societies or culture areas and are localized, folk, diagnostic [comma sic] categories that frame coherent meanings for certain repetitive, patterned, and troubl ing sets of experiences and observations.
42 The term culture bound syndrome has, in many ways, been a controversial topic since it has reflected the different opinions of anthropologists and psychiatrists. Anthropologists have a tendency to emphasize the re lativistic and culture specific dimensions of the syndromes, while physicians tend to emphasize the universal and neuropsychological dimensions (Prince 2000:431) (Jilek 2001). Understandings of the effects of excessive alcohol consumption could be classified as culture bound syndrome prior to medical evidence. Descriptions of di sease symptoms of inebriism, di p s omania, and other outdate d diagnoses for alcohol use resemble other folk diseases as they sifted through limited available medical and cult ural understandings of drinking patterns and effects and tried to unive rsalize a single phenomenon of alcohol addiction iii. Limits to Epigenetic Explanations for Alcoholism The medical profession has sought genetic evidence of an for alcohol. Studies have found genetic and environmental bases for alcoholism. The environmental factors (consumption of alcohol) allegedly lead to epigenetic modification of histones (acetylation and methylation) and DNA methylation, w hich can lead to the development of alcoholism. Both acute and chronic ethanol exposure can alter gene expression levels in specific neuronal circuits that govern the behavioral consequences related to tolerance and dependence. The unremitting cycle of alc ohol consumption often includes satiation and self medication with alcohol, followed by excruciating withdrawal symptoms and the resultant relapse, which reflects both the positive and negative affective states of alcohol addiction (Starkman et al 2012:296 ). and increased tolerance and worsened withdrawal symptoms. However, excessive alcohol consumption still inherently relies on the willful act of drinking, regardless of
43 how much epigenetic support exists for the physiological realness of the (addictive) impulse. Figure 2: This is a hypothetical model for the interactions of genetic and environmental factors in the predisposition to and development of alcoholism. (S tarkman et al 2012:297) Further, Starkman et al. propose that whole genome expression profiling has highlighted the importance of several genes that may contribute to alcohol abuse d proneness for relapse, they have yet to identify the specific genes which contribute to alcohol addiction. The Holden Police Department (for Kent State University) emphasizes the vastness of genes and potential gene interactions: What is the possibility that alcoholism is genetic and heritable? Per the Human Genome Project, there are 80,000 genes with approximately 3 billion different interacting combinations that exist in the human genome (the sum total of heritable, genetic material in a human being). Even the proponents of disease theory alcoholism have acknowledged that finding the gene that causes alcoholism would be like finding the gene that causes one to like basketball. The idea that alcoholism is 100% genetic and heritable is highly unlikely by all studies and statistics (HDP 2010).
44 the epigenetic modifications his genes have undergone. However, the molecular realness of addiction is only one component of a multi faceted condition. There are oth er explained wholly (or at all) by genetic factors. only the aspect of addiction, but also (addiction to be followed through via) the repeated act of drinking, and also an understanding of the point at which drinking habits are considered to be have graduated from matters of leisure to symptomatic reflections of addiction. iv. Medical Theory on the Object of Addiction A fundamental query of alcoholism as pathology theory is whether the alcoholic discussed previously was not necessarily medical, his ideas can be found in medical contex ts. Dr. Nora Volkow, a recent pioneer in drug addiction research, is committed to dopamine This bi nary of defining addiction can also be simplified as being a matter of biological inevitability versus unyielding habit, or by modern terminology the disease model versus the life process model of addiction, respectively. Each has the potential to both st igmatize and defend the addict or an addict population, in differing ways. The life process model of addiction (which can be applied more specifically to alcohol addiction) is the view that addiction is not a disease but rather a habitual response
45 and a s ource of gratification and security that can be understood only in the context of social relationships and experiences. The life process model not only claims the force of the addiction is a matter of will power, but further; that will power is a mental o bstacle which can also only be understood in the context of social relationships and experiences. This theory stands in direct opposition to the disease model of addiction. Part Three: M edical Anthropology and the Disease Model i. Re Contextualizing a Medical Concept When the disease like symptoms of alcoholism (laid out by medical approaches) resemble a form of deviance from the dominant cultural norms of drinking (laid out by anthropological approaches), it is clear to see how socially problematic drinking behaviors make the transition into disease symptoms The disease model of alcoholism, whether medically valid or not, exists in society. Medical anthropology must therefore evaluate it as the cultural health issue it is. It has been argued in t his thesis that the formulation of the disease model of alcoholism has been the medicalization of cultural elements. However, the disease model nevertheless exists, and it is medical or to re context ualize a medical concept from a cultural lens ii Medicalizing Human Nature and Quantifying of Culture Healy alleges that the way the categories of the DSM are st ructured, and the generous increase in the number of catego ries, are representative of an increasing me dicalization of human nature. He argues t his could possibly be attributed to disease mongering by psychiatrists and the all time influential pharmaceutical companies (Healy
46 2006, 185) However, aside from potent ial economic influences the i ncrease in accessible medical knowledge and growing power and responsibilities of t he medical institution has initiated a trend of attempting to explain (flaw within) human nature by medicalizing it back out of the medical discourse after modern medical and anthropological insight debunking their legitimacy as medical disease s Dr. David Rudy emphasizes the point: "Like most of us, physicians make errors. For example, Benjamin Rush, t he father of American psychiatry, viewed 'negritude' [having black skin as an African or African American] as a special type of leprosy. Rush also viewed lying, murdering, and minority group dissent as mental illnesses. It is also interesting that Rush is responsible for the 'first clearly developed modern conception of alcoholism [which he considered a disease]. At various later dates American physicians have viewed drug addiction, hyperactivity, suicide, obesity, crime, violence, political dissent, and ch ild abuse as worthy of disease labels and hence treat 2013), (Rudy 1986: 98). On a section in his book on the limits of empiricism, Bruce Wilshire demonstrates that given spotty success in dealing with addiction cultu re wide, medical mat erialists push even more vehemently toward chemical therapeutic approaches to addiction. He cites Marc Treatment As one would expect, it details far flung, varied, and intricate pharmacological procedures in the most mathematically precise physiological terms. in these areas, recovery is usually a long term process that requires some counselling and therapeutic relationship for at leas t six months to a 1998: defaults the handling of addiction to lengthy (and probably costly) institutional involvement. The World Health Organization explains:
47 e impact of patterns of drinking, a score has been constructed and validated for the CRA of the year 2000 (Rehm et al. 2001; 2003b; 2004). The score and its underlying algorithms have been described in de tail elsewhere (Rehm et al. 2003b, 2004). It compri ses four different aspects of heavy drinking (high usual quantity of alcohol per occasion; frequency of festive drinking at fiestas or community celebrations ; proportion of drinking occasions when drink ers get drunk; distribution of the same amount of drinking over fewer rather than many occasions), no drinking with meals and drinki 2007:24) (emphasis added). By using algorithms and to measure disease patterns, cultural aspects become reduced to ncy of festive drinking at fiestas or community involving drinking, the higher the culture ranks in heavy drinking. One major di fference between how medical fields an d anthropology approach alcohol addiction is the data each uses. Scientific approaches to alcoholism look at rates of drinking pathologies by loo king statistically at data comp iled over a span of time from hospitals, police, courts welfare and other social agencies and physician s on the incidence of alcohol related phenomena in specific groups ( Snyder 1958: 1). The only alcohol related phenomena which will be represented in these data sources are medical or criminal situations where alcohol had already led to pressing health or legal problems for the person from whom data is produced. Meanwhil e, ethnographers collect data on a wide range of variation in drinking practices and in the pathological manifestations of (Sny der 1958:16) Institutionalizing a universal and quantifiable disease theory of alcoholism inevitably leads to societal exclusion, whether by means of law, treatment, or social acceptance in general Prohibition was perhaps the fir st attempt at containing alcoholism by prohibiting alcohol use altogether with a policy of abstinence. Disobedience turned
48 the user into a criminal Containing the individuals with the disease in various institutions or facilities also became a very conc rete outcome of a mythic ized concept of the disease. Institutionalization of this kind thus itself became an active agent in the myth making of the alcoholic as tainted and harmfu l towards the rest of society. Containment was viewed as a necessary segrega tion at times, and a resource for recovery rendered him disabled. The d subsequent morphing of it It is the first drink that gets you drunk. This is a n AA aphorism meaning that once an alcohol ic consumes the first drink, he or she is then an alcoholic. This is not true. This is not even supported by proponents of the disease the ory of alcoholism. Even the proponents of the disease theory alcoholism acknowledge that alcoholism takes at least several years to develop. There is no scientific foundation or substantiation for this saying ( HDP 2010 ) Institutions (such as Alcoholics Anonymous) which are not necessarily comprised of doctors and physicians can ( and do ) add to the medical definition of alcoholism. The apparent. The disease theory of alcoholism is interwo ven with different potential economic utilities, which have assisted in navigating to some degree the ultimate course the model takes institutionally. In 1956 for example, the American Medical Association voted to define alcoholism as a medically treatabl e disease so that such treatment by physicians would become eligible for payment from thi rd parties, or insurance companies The decision was not made on the basis of any
49 analysis of the scientific evidence it was made to serve financial purposes ( Hanson 1997 2013 ). In this way, simple linguistic alterations were c apable of shifting the definition of alcoholism in ways which re oriented the functions of the concept and its institutional responsibilities. L angu age was able to perform as a marketing commodity. In an instance of magic, an institution could transform a a billable diagnosis (White 2004 : 53). Many people's jobs and income depend on the beli ef that alcoholism is a disease ( Hanson 1997 2013 ). Depending on how the problem was framed, language could also determine the degree of ease or resistance citizens would an example, requires coercive tools of engagement, whereas a medicalized, face saving untary 53). Language could also dictate the phase through which the such as by tacking the modifier who has undergone the available treatments, he or she can graduate into a new and 53). Language of t he disease theory of alcoholism is also capable of negatively effecting economic outcomes While a disease built around alcohol consumption could prove profitable for some in treatment industries t he alcohol industry viewed such a theory as a threat to their sales and sought to protect their interests (White 2004: 54). In the 1940s, the alcohol industry pushed for the Research Council on Problems of Alcohol which included the product of their livelihoo d i n its
50 very name (White 2004: 54). for the same reasons for which Cha rles Durfee coined it in 1942. 12 The alcohol goal was to instill a compromise in which the disease theory would be modif ied to shift the problem and essentially the blame from the substance of alcohol to the drinker i ii Functionalism in the Disease Theories of Alcoholism One way of reconciling medical and cultural approache s is to use an approach which asks a question answerable by neither medical nor social discourse exclusively. At the time, f u nctionalist approaches were popular in studying alcohol. Functionalist thinking provides the prescriptive, processual course of l ogic which could be responsible for linking alcohol consumption with physiological disease concepts. Social anthropologists have created theoretical formulations for analyzing drinking behavior by means of categorizing the social and psychological functi ons drinking assumes in a culture (Pittman 1967:4). Alcohol makes the major transformation from a mere substance into an embodied material culture and a generator of individual and national identity, but only when consumed in a socially relevant context. analyses often were drawn by the logic of (at least implicit) polemic into a functionalist (Dietler 2006:230). 12 As discussed in Chapter I, drinking, but without labelling them as diseased.
51 For example, ies of primal needs and addictive behavior functionalist theory of needs. this context also demonstrates why the disease model may have arisen, or what function it has. The theory of needs was a functional and partially biologically deterministic approach to linking the individual and society. According to Malinowski, culture exists to meet the basic biological, psychological, and social needs of the individual. So what function does drin king have for biological needs, especially since its digression from its more primitive and experimental medicinal functions into the realm of leisure? Anthropologists, social scientists, biologists and psychologists might answer this question differently Need for higher cognizance, hedonistic euphoria, enlightened intellectual experience, escape and relaxation is one more metaphysical answer. alcoholism as a response to the basic needs of restored health which mythically creating disease diagnoses satisfies, in a magical and pre scientific yet functional way Limited knowle man to conclude that illnesses are caused by sorcery 2012: man, primitive or civilized, wants to feel that something can be done. He craves for 2012: 142). Alcohol having been viewed as an elixir of life and purveyor of immortality was permitt ed as a rational belief before modern scientific understandings of alcohol (as well as mortality) erased not only the logic, but also the A quote from Quarterly Journal of Inebriety (1897) also demonstrat es an approach to the underlying draw towards intoxication. It is provided in a vastly different
52 context (both in terms of its era and attitude toward alcohol intoxication), and serves as a stark contrast for emphasis : bnormal and defective organic conditions exist prior to all use of spirits. The use of alcohol deranges first of all the psychic life with its sensations, desires, feelings, volitions, memories, reasonings, inventions, etc., also the relations to the surr oundings. Alcohol attacks the organic harmony organism is unbalanced, his mentality is deranged, and this increases with the use Crothers cites indi vidual ineptitude and defectiveness as the underlying drive towards isolate and demonize the alcoholic for his wrongful and destructive pursuit of intoxication, Wilshi is is an extreme example of contrast, but it demonstrates the different attitudes towards alcohol addiction which can arise if the fundamental desires which bring the drinker to drink are condemned as ill and immoral as opposed to healthy and universally r elatable. iv. Conclusions Constituting a disease theory of alcoholism has not always been a ploy to posit blame upon the drinker within profiteering agendas. However, whichever shifts are made within the disease model of alcoholism whether in blame, the object of addiction, or the degree of volition the alcoholic can claim all factors were still allegedly attributable to disease. Therefore even if the phrasing of the theory was meant to defend the alcoholic siologically
53 inherent to him. His identity becomes reducible to that of an alcoholic upon diagnosis, rather than a person who merely possesses unusually excessive drinking habits or an addiction to alcohol. It is untrue that scientific and cultural study of alcohol and alcohol addiction must exist dichotomously and that their motives always contradict. Medical perspectives need not undermine the efforts of anthropologists attempting to study alcohol for its cultural relevance. Scientific and medical appr oaches can contribute to an understanding of the biological precursors which may influence the behaviors which eventually make up addiction. However, studies which stubbornly maintain purely medical explanations for alcoholism (i.e. direct and identifiabl e genetic predispositions) ought to be approached with ample discretion, as there are still behaviors which must have led the alcoholic to continually pick up the drink prior to the more complex formation of dependence or addiction. Most scientists today who do support the disease model of addiction believe it is an acquired disease, as opposed to a congenital disease. While medical approaches look at drinking behaviors as symptomatic compositions of what ultimately does or does not become the disease of alcoholism, social anthropologists create theoretical formulations for analyzing drinking behavior by means of categorizing the social and psychological functions drinking assumes in a culture. Therefore, the argument of this thesis needs the resource of medical approaches (spe cifically ones which provide evidence used to construct the disease model), but it ultimately requires an anthropological approach to bridge the cultural functions of drinking with its alleged disease like outcomes.
54 III. Pragmatic Applications and Limitations of Disease Theory of Alcoholism : Cases and Examples i. Introduction The etiology of the disease diagnosis, particularly within the DSM, demonstrates a move towards object ivity, biology, and removal of cultural elements of alcoholism. These cultural elements include how it is perceived (both inter and intra culturally ) as well as how it spread to and within that culture (epidemiology) an d the forms it assumes. In other word s as the definition of alcoholism has become more scientifically specified, it has simultaneously diminished in its acknowledgment of culture. This can be for both the better and the worse, as far as ethnocentrism and fairness are concerned. The cultural ele ments which in filtra ted the concepts of inebri ism and dipsomania were discriminatory ones; they depicted the addict as deviant rather than a victim either of the strength of his habit or his physiologic al disease. A move towards objectivity in the definit ion of addiction potentially corrects the problematic stigmatizing of cultural or economic groups However, while a move toward objectivity can seemingly eradicate specific, discriminative criteria of a racial, ethnic, or class group lism, it can also carry out the same stigmas in different ways, such as generalizing beliefs regarding of alcoholism within their demographic. Either way the unive rsal ized m edical definition of alcoholism is likely to confuse cultural or behavioral issues with biological ones. The case studies are chosen for this section of the thesis to demonstrate the fallacies of the disease model of alcohol addiction (as define d and described in recent
55 publications such as the DSM). Each example is incon sistent with a legal or medical or is not a dequately explained by it. 1 Case Study 1: Powell v Texas (1968) Figure 3 : < http://www.stus.com/stus cartoon.php?name=Powell+v.+Texas&cartoon=crl0051 > i. Aspect of Disease Theory Challenged This case study explores one pragmatic function which the disease concept may serve excusing in a court of law the criminal acts which are allegedly directly caused by the diagnosable condition of alcoholism w hich the perpetrator suffers. As discussed in the previous chapter, a plentitude of crimes hav e been affiliated with drinking and drunkenness both directly and indirectly This example specifically lo oks at public drunkenness as a crime in its violation of the Texas Legal C ode. The sta tu t e itself can be deliberated for the level of morality that goes into making a seemingly harmless display s intoxication by a substance consumed legally no less into a convictable crime. However, this section does not focus on judgment of public dr unkenness. It 1 The examples chosen are not meant to reproduce stereotypes of social stigmas, but are intended to illustrate the shortcomings of a disease model of alcoholism for accurately depicting the situation of high or low prevalence of alcoholism within a specific cultural group.
56 focuses more explicitly on showing the ways in which the disease concept is conveniently molded to fit the given case, and the conceptual and pragmatic limitations of the theory as it is implemented in a court of law. Supreme Court case Powe l l v Texas (392 U.S. 514) represents t he appeal of a vious legal conviction in criminal court, which determined that he was guilty and responsible for behaviors while intoxicated in public. T he arresting officer testified that he had observed appellant in the 2000 block of Hamilton Street in Austin; that the appellant staggered when he walked; that his speech was slurred, and that he smelled strongly of alcohol. He was not loud or boisterous; he did not resist arrest; he was cooperative with the officer. Powell was a man of low socioeconomic status. According t o his testimony, he worked at a tavern shining shoes and made twelve dollars a week, which he would spend on wine. He had a family he did not financially support. Also according to his testimony, he drank every day and got drunk once a week, in which or interfere with others ( LII 1992 ) He had been arrested one hundred times before for public drunkenness since 1949 ( LII 1992 ). tion were viewed as a violation of Article 477 of the Texas Penal Code, which reads a state of intoxication in any public place, or at any private house except his own, s 2013:619 ). 2 The appeal centered on the de held to be a disease. And according to a precedent set by a previous court case, Robinson v California of (1962 ), the acknowledgment of Powel l having a disease was the key factor 2 The appellant was originally tried with this violation in the Corporation Court of Austin Texas March 7, 1968, where he had been found guilty.
57 which ought to change the verdict by the Court. The reversal was rejected four to five Four justices accepted the disease concept (th e reversal). The other five justices did not accept the disease concept of alcoholism, at least in that it may serve to pardon the crime of public drunkenness for which Powell was originally co nvicted. One swing vote, Justice Byron White, accepted and sympathized with disease theory but did not feel this case fit that diagnosis (Fingarette 1988 :2) P owell v Texas unfolded upon a crest of newfound literature and theory on the disease concept of alcoholism. The case occurred only two years after the A merican M edical A ssociation declared it a medical concern and a mere six years after A merican P sychiatric A ssociati on put out their first Diagnostic and Statistical Manual of Mental Disorders (DSM I) to define alcoholism for the purpose of diagnosis by specialists Still, t he concept was only ambiguously understood and was young in the medical literature. Despite th e and woefully deficient medical understandings o f alcoholism and mental illness, they nevertheless claim ed as a hard fact that alcoholism is medically recognized as a d isease (Fingarette 1988:5 ). The dissent conclu the core meaning of th e disease concept of alcoholism was that alcoholism is caused and maintained by something that, to a greater or lesser extent depending upon the physiological or psychological makeup and history o (Fingarette 198 8:5 ). The defendant in Robinson v California Robinson was convicted by a jury under a California statute which made the use of narcotics s whether a law making a criminal
58 offense of a disease, namely drug addiction, is an infliction of cruel and unusual punishment. The concurrence sa id it was, because addiction was an illness and therefore could no t be made illegal T he Court was more concerned that in punishing addiction, the Defendant is punished for the mere d esi re to commit a criminal act, with n o proof of actual drug use is required. Hence, the statute was unconstitutional (Robinson 1999:420). This, they felt, was more important than the validity of the disease concept. As per the disease theory of alcoholism, excessive drinking is considered an involuntary symptom which carries out the d isease, and public drunkenness would be one status and excludes from its scope any anti social ated w (Fingarette 198 8: 3). The mere applicability of Robinson to Powell is uncertain The disease theory of alcoholism intended function in cour t was to pardon an ctions as inevitable symptoms of his diag nosis therefore suggest ing that to convict him based on his disease is contrary to the precedent Robinson v California H owever the legal significance of the disease model and the volitional incapacity of the David Robinson Jr. 3 states: In the course of ruling on whether an alcoholic could be criminally convicted and punished for being intoxicated in a public place, consistent with the prohibition of was required to consider the constitutional status of the actus reus requirement, the insanity defense, the meaning and legal significance of disease and volitional incapacity, limits on the use of criminal sanctions and what constitutes the constitutional restraints on social policy in the empirically and normatively complex area of substance abuse (Robinson 1999:401 ). 3 (not of Robinson v. Calif ornia)
59 The P owell dissent chose to label pub lic drunkenness as a condition rather than a conduct. Using in describing public drun kenness is a tricky choice of words because it is obviously at least in part a behavior. The dissent resolves this contradiction by arguing tha t it can be seen as a part or effect of disease and it is thus a behavior which is also inevitably symptomatic. provides more than ample warning of the catastrophic consequences that may flow from imposing sanctions for what people are rather than for what they ha ve done 1999: 420) efs therefore insist that a precedent like Robinson should not be extended beyond crimes of status 4 to invalidate crimes of anti social behavior. situate d the case under the presumed scope of the Robinson v California precedent: 1. power to resist th e constant, excessive consumption of alcohol. 2. That a chronic alcoholic does not appear in public by his own volition but under a compulsion symptomatic of the disease of chronic alcoholism. 3 th th e disease of chronic alcoholism (Fingarette 1988 : 4 ). All five judges against the appeal agree that recogniza ble, traditional sense as recognized anywhere in the court of law. The first two present sweeping gen eralizations which rely on two underlying assumpt ions, without argument would falter. The first 4 protecting an individual from being convicted based on the simple fact that he is addicted
60 second assumes the scientifically inevitable relationship between the status of chronic alcoholism and the acts of public drunkenness. claims the first two facts alcoholism, as far as the Court was to be concerned. iii Limitations The court is one place where the legitimacy of the disease concept is legally decided for pragmatic application; in this case, for its legitimacy in pardoning Pow ell of fault from his own crime. This is because it is intricately argued on both sides by nature of the process of trial. The shaky foundation for the disease co ncept at least as fa r as the dismissal Utilizing medical knowle dge in a court of law highlights the complicated issue of situating scientifi c information within a legal and moral framework What seems like professional support may actual ly be an attempt to conflate medical diagnoses with a statement on behavioral morality and legality. The main testimony in Powell v Texas and alluded to the ongoing debate within the medical profession over whether alcohol is physically addicting (as per a disease model) or psychologically habituating (as per a life process model). Wade concluded that a chronic alc oholic is an involuntary drinker who loses self control over his drinking. Wade went on to testify that Powell was in fact a chronic alcoholic with an uncontrollable compulsion to drink. On cross examination, Wade admitted that when the appellant was sober, he knew right from wrong. He stated that Powell has an uncontrollable compulsion to drink and he does not have the
61 willpower [to resist the constant excessive consumption of alcohol or to avoid appearing in public when intoxicated ], nor has he been given medical treatment to enable him to develop this willpower ( LII 1992 ). riminal penalties may not be inflicted upon a person for being in a condition he is powerless to 1998: 4). This essentially excuses all resulting actions a person makes that is a resultant of his disease. However, Powell dissent errs in implying that the ical literature implies ab sence of volition (Fingaret te 1998: 12). Hypotheses stating involuntariness need to confront the fact that some people have enjoyed periods of abstinence or voluntarily seek a cure for themselves (Fingarette 1998: 10). Regardless of whether or not his st atus as a chronic alcoholic was confirmed with a disease diagnosis, such a vague, non universal, and non conclusive diagnosis could do little to shield him from his own volition in committing the behavioral crimes which stemmed from his diagnosis rather th an the crime of merely being an alcoholic, which was appealed in Robinson v California. Leroy Powell lost his appeal to the Supreme Court. T herefore, t his case could not serve as a precedent for later cases attempting to eradicate criminal fault on the basis of being ill argument of this thesis. The dissent was attempting to segue the precedent set by Robinson v California using this status to pardon criminal behavior. They did not succeed. Interestingly, the issue was not one of concurrence over the disease aspect of alcoh olism a slight majority of justices agreed alcoholism could be considered a disease. However, they did not feel this
62 medical assertion had the leverage needed to pardon even a non violent (and arguably victimless) crime, despite it having been committed s ymptomatically. The disease diagnosis of alcoholism failed to serve the pragmatic function it was intended to in this court of law to argue the difference between addicted status (upheld by Robinson ) and ) was negligible due to the appeal. Case 2: Mission Indians of South California i Aspect of Disease Theory Challenged The second case concerns the Mission Indians of South California. This case demonstrates the pragmatic limitations of ethnocentrically using a disease concept of alcoholism to describe the conditions wit h than the APA and other groups administering the disease model of alcoholism. It also accentuates historical situations of exploitation which have driven the Mission Indians toward alcoholism, which cannot be fa irly accommodated as purely genetic or biolo gical proneness. This case is also notable however, for the extensive research available on potential biological factors affecting alcohol use by the Mission Tribe as an ethnic group. This case also focuses on the contradiction of the slightly above normal incidence within the Mission Tribe of the allele ALDH1A1*2, which protects against alcoholism, despite their disproportionately high prevalence of alcoholism. This suggests potenti al historical
63 and cultural instigators for the heavy use of alcohol within the group, which cannot be thoroughly explained by biology or genetics. Most of the Native Americans of this region affiliate with the Mission Tribe. This tribe, and any which resi de in the demonstrated region or otherwise, share the fact that colonial encounter, as their land became infringed upon by Europeans and the consequences of European i nteraction. Thus a brief note to the role of the colonial experience on Native American alcoholism is not only relevant but a crucial explanatory device. The introduction of this thesis discusses the different reasons behind drinking as it exists in cult ural patterns. For Native American groups, reasons underlying excessive drinking are rooted in oppressive colonial contact and deliberate marginalization. The Native Am ericans were faced with and encouraged to drink large quantities of potent spirits in a system of exchange which was more exploitative than it was mutually beneficial. These liquors were far more potent than the kava they were accustomed to. Such potent substance s given in large quantity to a vulnerable group made them increasingly more vu lnerable (Mancall 1995:16 ), and enforced a power dynamic built around the politically motivated supply of the Europeans and the deman d from the Native Americans. occurred a midst other imperi alistically motivated actions such as the removal of children from Native American homes and the isolation of organized reservations (Sager 2008 ). Each of the latter implements sought to stifle generational cultural advancement of the N ative American people Alcohol, too, can be seen as an intentional tool of control used by the
64 early colonists upon the Native Americans. It was an imagined vector of disorder, a source of colonial and post colonial state revenue, and a component of subversive alternative economy all at once (Dietler 2006 ). While these are harmful colonial policies which affected Native Americans across the country the focus of this case study is the Mission Tribe, specifically. The encounters of the South Californi a Ind ians with colonists began with Catholic priests who for bid them from practicing their native culture, which resulted in the disruption of many tribes' linguistic, spiritual, and cultural practices. The Mission Tribe, as all affiliated tribes would c ome to be termed collectively, was named after the mission which coerced their labor In 1769 the first Spanish Franciscan mission was built in San Diego. The mission extended to San Francisco. Tribes native to this relative area were relocated around the construction of the project. Mexico gained control of Californian missions in 1834 and abuse persisted. The term "Mission Indians" was initially applied to Southern California Native Americans as an ethnographic and anthropological label around 1906 by anthropologists Alfred Kroeber and Constance G. Du Bois at the University of California, Berkeley at Mission San Luis Obispo de Tolosa and south. It is worth noting the environmental fac tors contributing to the spread of disease which She In t his particular context, Cook refers to disease as a basic of new maladies introduced by the new, invading race with which the established race has had no experience. Yet, aside from the lack of immunity thus assumed, the intensity
65 of the disease factor may and will be conditioned by subsidiary or secondary facto rs 1976: 30). Cook then goes on to list environmental factors which contributed to diseas e and contagion in the missions; sexual relations, aggregation, intercommunication, change of climate, bad sanitation, poor diet, and lack of treatment (Cook 1976: 31). Cook does not attempt to include the disease of alcoholism (explicitly, at least) in the process of contagion he is trying to explain, but one may see how alcoholism, as a disease, may easily fit into the model for contagion he lays out. explains the spread of diseases increasing based on the gathering of large numbers of Indians in one place far more than in aboriginal conditions. This is precisely how alcoholism spread within the tribes of this region. Alcoholism most assuredly occurred in the contact of two groups, and spread along with some of the same environmental factors Cook lists. However, contagion as it is understood medically has long been debunked within an interpretation of alcoholism, even by disease model proponents. Thus, while we acknowledge the roles that coerced social grouping and imperialist encounters played in initiating the patterns of excessive alcohol consumption among the Mission Indians, one can do little more than analogize if attempting to describe their alcoholism as a biological disease. In his analysis of alcohol as material culture, Dietler places alcohol in the food category, as opposed to Cook, who distinctly clarifies considered a food or dietary factor and hence must be excluded from that general 1976: 492). He feels t he alcohol problem must be add ressed in broad study of social relationships. Applying a disease concept to alcohol use, how ever,
66 forces the confrontation of alcohol into the same arena of factors which describe diseases among cultures (such as aggregation). Historical situations considered, the majority American population (the one which these definitions are typically targeting) experiences alcoholism today are represented by two different major points; f irst, the discrepancies between t heir concept of what disease is; s econd, how alcohol affects those w ho do drink, genetically and socially. ii Limitations One major reaso n the disease concept does not efficiently project onto The Mission Indian example is that the definition of disease alone i s ethnocentric. T he applicability of a definition of disease (particularly regarding alcoholism ) to a group which conceive s differently of disease inevitably leads to an incongruence of terminology and thought Williams and Ellison (1996) discussed the differences in how Native Americans view disease as c ompared to Western medicine. Rather than disease being something mechanistic and physiological in nature, Native Americans generally view disease as a disruption of the harmony that exists between mind, body, and spirit. Thus, Williams and Ellison argue th at it is more efficacious to treat Native Americans in a manner that respects this understanding of disease. Examples of such treatment modalities include: tribal ceremony and ritual, sweat lodges, talki ng circles, and medicine wheels ( Sager 2008: 7). The application of popular disease diagnoses upon Native American groups also inevitably involve the treatment options through which a diagnosis is followed through. P roponents of using A lcoholics A nonymous for Native Americ the twelv e steps can be easily adapted to Native American beliefs, and thus usefu l for them (Garrett and Carroll : 2000). Others view AA as being incongruent with Native
67 counte r to the private family centered setting traditionally viewed as the site of handling problems (Kinney and Copans 1989 :142 ). Bell (1988) pointed out that cultural dislocation (the feeling of not fitting into either traditional Native American culture or American culture in general ), the lack of clear sanctions or punishments for alcohol abuse, and strong peer pressure and support for alcohol abuse are all risk factors for Native Americans. Baruth and Manning (2007) also provide the following list of ris k factors that Native Americans face in relation to alcohol abuse: f ailure to develop a strong cultural identity and a positive self concept; a dverse effects of discrimination; p oor English proficiency and confusion in communication; i nability to reconcile American Indian cultural values with other cultural values; l ower academic achievement after fourth grade; a nt and low socioeconomic status ( Baruth and Manning 2007 :3 ) In addition Baruth the distributor of treatment, assess the level to which the client is acculturated to mainstream soci ety. Williams and Ellison identified four styles of living among Native Americans, which each fall on a continuum of acculturation. They are: traditional, marginal, middle class, and pan Indian. Each of these different styles represents a different ( Williams and Ellison 1996: 4). Identifying levels of acculturation is relevant in is suing treatment, but not necessarily in determining likely etiological components that brought them to disease. The early or adaptive stage of alcoholism is marked by increasing tolerance to alcohol and physical adaptations in the body which are largely unseen. This increased
68 while appearing to suffer few effects and continuing t o function. This tolerance is not created simply because the alcoholic drinks too much but rather because the alcoholic is able to drink great quantities because of physical changes goin g on inside his or her body. This assumption seems to contradict the c ase of alcoholism among the Mission Tribe. I n (published independently and further referenced by Betty Ford Institute ) 407 Mission Tribe Indians who would be deemed alcoholics by DMS III 2 standards were found to have similar type and degree of progression of alcoholism as general population (this advocates theory of a temporal process of alcoholism relatively unaffected by ethnicity). This is to be expected, as ethanol is a constant and it will treat fellow human beings very similarl y. Ethanol and the objectivity of its effects is not aware of ethnic, racial, and cultural differences. However, the condition also does not exist separately of the human bodies which manifest it. The human vector is not just a host for the disease but a host of complexities and subjective aspects of alcoholism, including how that person views his or her own condition, if that person even considers his or her habit a disease, and a variety of behaviors and habits which can be affected by This is evident in the differences between the Mis sion Indian alcoholics and the general sample group of alcoholics referenced by the Collaborative Study on the Genetics of Alcoholism (COGA ). 5 5 The COGA uses an assessment (that is both genetic and behavioral) called the SSAGA a poly diagnostic interview (DSM III R, DSM IV, ICD 10) with an emphas is on substance use and co related diagnoses. It assesses common psychiatric disorders prevalent in a general population, and occurring with greater frequency in alcoholics and substance abusers and their families. Special attention is paid to the interrel ationship of substance use and psychiatric diagnoses. However, there is a cultural component in such an assessment, as a disease in its medically manifested form can be objectively seen only in its
69 Mission Indians in this study were significantly more likel y than alcoholics in the COGA to experience binge drinking, physical fighting, driving while intoxicated, and alcohol related health problems and were less likely to consider themselves excessive drinkers, drinking where and when they had not intended to, and to experience guilt concerning their drinking. Rates of abstention after an alcohol dependence diagnosis (61%) and remission from alcohol dependence symptoms (77%) wer e also high in Mission Indians (Ehlers et al 2004:1204 ). T here is actually a great er percentage of abstinent Native Americans than there are in the general p opulation. The problem lies in how alcohol affects those who do choose to drink. There are undeniably some biological and genetic factors whose presence in turn may act to prevent Another major finding of Ehlers expe riment is the negative association between a lifetime diagnosis of alc ohol dependence (as judged by DSM III standards ) and presence of the ALDH1A1*2 allele. This allele was found to be slight ly more common in the Mission population in compa rison to the general population (proportionately), yet the Mission Indians also have the highest rates of deaths of alcohol related deaths of any ethnic group. The research finds that ALDH1A1*2 protect s against developing alcoholism in Southw est California Indians yet despite its similar (and slightly higher) incidence in this population, prevalence of alcoholism is very high within this group especially compared proportionately to other groups Ehlers et al. list with similar incidences of the same allele ( certain Asian Caucasian, and African American group s) Additionally individuals with the ALDH1A1*2 allele reported lower levels of drinking when they first started drinking regularly and reported d rinking half as many drinks as individuals with the ALDH1A1*1 individual hosts. The SSAGA assessment gains validity in These cultural conditions (as seen in this case study) may be significant enough as to culturally perpetuate many of the qualifiers of lifetime alcohol use which, as the SSAGA interview and DSM assessment may determine, would brand that culturally fated person the label of alcoholic.
70 allele when asked what was the maximum number of drinks they had ever consumed over a 24 hour period. P articipants in the study who had ALDH1A1*2 also reported significantly less positive expectations of alcohol, which may support the idea that they have an altered response to alcohol ( Ehlers et al. 2004: 1485) (see Figure 4) Figure 4: Expectations of the effects of alcohol according to surveys from Mission Indians, grouped by allele carried. Carriers of the ALDH1A1*2 allele have lower expectations of alcohol, universally (Ehlers et al. 2004:1485). Ehlers (et al) compared their findin gs with specific Asian communities who exhibited high incidence of the same allele, yet in these communities, prevalence of protective qualities were reflected on the societa l level, rather than simply the individual. The exact mechanism whereby ALDH1A1*2 influences drinking behavior is not clear, but these data suggest that the protective association between ALDH1A1*2 and alcohol dependence is mediated in part through lower levels of alcohol consumption ( Ehlers et al. 2004: 1484). Thus, this allele is preventative against alcoholism indirectly it provides the drinker with a negative experience of alcohol consumption which is likely
71 to keep him from volitionally developing the habits which lead to alcohol addiction (most markedly continued drinking). This allele functions for the individual in much the same way the pharmaceutical drug Dalfirum 6 does for lessening the hold of the temptation to drink by ruining its appeal. vi Conclusions These two examples demonstrate th e limitations of disease theory of alcoholism conceptually or pra cticality Each identifies a specific component of disease theory which it challenges to demonstrate different ways in whic h the disease theory fails to represent The Powell v Texas case study demonstrates how, in a court of law, a disease status of an individual does not necessarily protec t against the behaviors which de rive from the condition. The defense had attempted to use the disease theory to protect and defend Leroy Powel l from a conviction based on symptomatic behaviors, arguing such a conviction to be a violation of the Fourth and Eighteenth Amendments to the Constitution (cruel and un usual punishment), and a contradiction to the precedent set by Robinson v California In the end, although Powell had been confirmed a chronic alcoholic by a psychiatric professional, there was no legal obligation to uphold the disease theory of alcoholism, and the diagnosis fell through as valid arguments according to the (slim) majority of justices, who denied the appeal. A large and persuasive part of the disease concept of alcoholism involves the holic may or may not be able to refuse to drink, a group adhered by cultural membership that emanates high levels of alcoholism, 6 Dalfirum is discussed briefly in the Introduc tion.
72 may have experienced certain precursors that had manipulated its inclinations toward excessive alcohol consumption. These expl anations can most explicatively be approached by anthropologists. Marginalized groups lesser able to determine their fate or to control the exploitative measures that faced them were involuntarily subjected to conditions which directly produced their patt erns of prevalent alcoholism. The Mission Indian case thnocentrism by the disease concept imposed upon a phenomenon of their alcoholism at large. Further, this case highlights a contradiction between expectations of protective factors of ALDH1A1*2 may be biologicall y supported, but this does not directly trans late into deterministic fact in (an attempt at) objectively defining and examining the parameters of alcoholism the disease. Since t here is actually a greater percentage of abstinent Native Americans than there a re in the general population, it is evident t he problem more so lies in how alcohol affects those who do choose to drink. However, the fact that they actually have high levels of alcoholism suggests something else is contributing to the tendency toward alcohol abuse, which are possible attributable to social and historical forces.
73 IV. Conclusive Analysis i. Metaphor in the Disease Model This thesis has introduced a breadth of approaches interaction with alcohol is conducted While anthropology looks at alcohol i n regards to hu man kind culturally, scientific fields and the medical institution are interested in body pathologically. However, c ultural and scientific approaches need n ot become mutually exclusive. Medical anthropology reconcile s the cultural and t he medical spheres in regards to alcohol consumption because it examines the ways in which culture and society are organized around or influenced by issues of health and illness However, t he medical anthropo logist looks at health a nd illness n ot plainly as objective medical fact but also as they exist as cultural constructs I n this thesis, I have taken a medical anthropological approach in critiquing the medical assertion that is the disease model of alcoholism. As I have shown, this model is itself a cultural construct, and it falls short of accomplishing its intended task of (non discriminately) identifying and diagnosing a real, pathological disease which sets the alcoholic apart from other people, or even other drinkers. A disease model end s up forcing a n unfit and culturally construed metaphor in order to justify its existence. A disease theory of alcoh ol addiction s uggests chronic drinking i s a problem which has germinated within the drinker, from the inside out. 1 Dependence can be viewed as physical, in the form chemical dependence; or mental, in the form of psychological dependence (desire). As explored in Chapter II there is a lack 1 The disease theory does recognize environmental ly induced factors of alcoholism, but even these are believed to become internalized once they have contributed to disease.
74 of agreement as to the object be included within the disease model, as there is no singularly accepted criteria for this model The disease theory goes too far with its metaphor linking the seed of alcohol dependence with a seed of etiological disease germinating in the body because th is disease cannot exist without the necessary acquisition and consumption of alcohol (and the embodied effects of the alcohol once consu med) which are externally sourced This conflates the external and internal, and in the transition, cultural ly varying factors of chronic alcohol addiction become disguised and misrepresented as internalized physiological factors Michael Dietler has e xplained alcohol as material culture which aids in identity transformation once consumed. On the smaller scale, the intoxication caused by consumption psychoactively alters the mental state and ontological experience of the consumer. On the larger scale, drinking, and he can experience a transformation of identity if he deviates from these norms. This latter identit for ex cessive alcohol drinking that are primarily accepted in that culture. Similarly, the general consumption of alcohol as a collective cultural activity parallels its transformative process, as it does through the aforementioned individual am ong a group of people, but if drinking becomes a pattern within a group of people within a shared class situation, the transformative identity process involved in common eing
75 subjective identity, classification of alcohol consumption aids in identity construction. When the authoritative diagnostic source administers linguistic tags such as it is not just the level of consumption but also the individual (or group of diagnosed individuals) who become classified. The diagnosable qualifiers of alcoholism the disease must rest upon notions of social deterioration, according to the me dically accredited manuals published by the WHO and APA. The conflated concept that a medical condition can be measured in part by social deterioration is evidence of the co nflation of cultural (dys) functioning with pathological illness. The diagnoses al so acknowledge bodily and mental deterioration, as a disease would induce on the body. Alcoholics Anony mous and other disease theory twelve step groups are actually using a non medical approach. Dr. Stanton Peele observes that "Why supposed medical trea tment consists mainly of going to group meetings and why people can't develop their own spiritual approaches to life if they choose are questions disease theory adherents igno 1992:20 ) (Hanson 1997 2013 ). In fact, it has been argued that allegi ance to the disease model of alcoholism i tself is tantamount to The construct of the disease theory of alcoholism is closer to being a religion than it is to being a disease Why do I say this? Because in order to believe in the different tenets of disease theory alcoholism, similar to religion, you must have faith. None of the tenets of disease theory alcoholism have ever been supported by scientific or doctoral level resear ch. It is faith alone which allows these tenets to exist (HDP 2010 ). (primal) needs, if we conclude that a disease model is built upon faith as it is a culturally
76 proposed explanation for an apparently debilitative phenomenon (chronic alcohol addiction) about which we have no conclusive scientific answers. i i Medicalizing Alcohol Addiction, Perpetuating Stigma The apparent assumption that medicalizing a condition reduces its stigma presents a peculiar contradiction. Designating addiction as a disease causes the condition to seem just as inherent to the addict, but without the moralistic blame that is attached to the hich predates the disease diagnosis). However, not only is it still humanly limiting, but this action perpetuates certain status hierarchies and the new physician specialty of addiction medicine. The medicalization of addiction was as much about the desired prestige of the caregivers as it was the destigmatization of alcohol and d rug Under the disease model of alcoholism, t he etiology of excessive drinking is thought to be hereditary and the sufferer was thought to be chronically debaucherous in general. Such innate causes both pardons the drink itself from stigma, and also ostracizes the sick drinker on a deeper and more innate level. Rush was actually attempting to defend heavy drinkers in his treatise by pinning their habit on disease, bu t the disease was both considered heredi tary and a precursor to a slew of crimes such as murder. Thus, while attempting to remove responsibility from the drinker, the diagnosis paradoxically became far more problematic, as it was a matter of ones deepest character as opposed to a disease which came about from a poor decision.
77 The diagnosable qualifiers of alcoholism the disease must rest upon notions of social deterioration, according to the medically accredited manuals published by the WHO and APA. The conflated concept that a medical condition can be measured in part by social deterioration is evidence of the conflation of cultural (dys)functioning with pathological illness. The diagnoses also acknowledge bodily and mental deterioration, as a disease would induce on the body. i ii Deviance and Mental Illne ss Notions of deviance feed into negative constructions of the chronic drinker as debaucherous and socially ill. In constructing a disease theory of alcohol addiction and cloaking it in unobjectio nable medical rhetoric, many subjective ideas of deviance become disguised as objective traits. person who has an addiction The first phrase implies that a person, who claims autonomy as such, possesses a quality secondary and supplementary to his personhood. The second phrase is not a phrase at all, but a singular the person it describes. It is a classificatory diagnosis, which transforms a person into an alcoholic interchangeably. A disease with an unobjectionable scientific epidemiology would be understood from a positivist perspective, because a person physical ly experiences the disease and does not physiologically experience it any more or less in relation to other sufferers. The negative connotation of alcohol addiction is a result of its overarching and long spanning regard as deviant like leprosy and other conditions which have acquired deviant
78 reputations based off superficially unappealing symptoms The presence of deviance is universal, while the deviant behavior themselves are not. "'Deviance is not a property inherent in any particular kind of behavi or; it is a property conferred upon that behavior by the people who come into direct or ind irect contact with it.'" (Erikson 1966:6 ) Therefore, the diagnosis of alcoh olism as objective ultimately is (perceived as) objective due to the complex, socially constructed decision to deem alcoholism a disease. roblem drinkers pondering a diagnosis of alcoholism emphasize the positivist concepts of central tendency, objectivity, and prediction/control. Positivism reinforces the value of normality even (Young 2011:380). In regards to societal regulation of normalcy (or against deviance), behaviors and patterns are created in the affirmative (inclusory) or negative (exclusionary). Threatening the punishment of stigma and/or disease ensures societal norms of drinking are adhered to. However, because alcohol is not truly a disease in the same sense of others which can be caught, there can be societally granted exceptions to general r ules, and these offer immunity from disease Recall from Chapter II the social rules for day drinking exceptions which Dwight Heath put forth. The u nderlying forces (class, elitist wealth celebration, trend) behind these exceptions suggest conditions o f privilege can shift and evade what would typically be stigmatic. acknowledgment that there is liquor in their breakfast drink. I disagree with this assumption. Naming drinks is a popular phenom enon and it is a trending universal code which can be utilized by consumers and understood by bartenders regardless of the time
79 known and clearly recognizable to the extent of the Bloody Mary or the imosa (or even conspicuously served in a champagne flute), it loses its function as a code. Ordering the Bloody Mary or Mimosa with breakfast is a very intentional engagement with the brunch sumption from reproach T he individual is taking advantage of the pardoning circumstances, and retaining his or her socially acceptable identity while seemingly breaking a general rule. I would argue this notion offers a risqu appeal of its own, and has brought popularity to the Bloody Mary it may never have had were it a late evening drink. iv Questioning the Autonomy of the Disease Theory The consumption o f dietary substances (junk foods) or drugs (pharmaceuticals, other psychoactive substances, nicotine and caffeine) other than alcohol can cause the same deterioration, but do not have their own disease concept linked to their habitual usage. Bodily and mental deterioration, in contingence with inevitable social deterioration, are the components which, when bound, complete the disease model of alcoholism. Other addictive substances cause bodily, mental, and social deterioration like alcohol, but are not given their own conclusive disease concept. Alcohol is therefore an arbitrary choice among t hese other substances. The disease diagnosis of alcoholism cannot stand on its own as a concept, the alcoholic volitionally chooses to stop drinking. Therefore, th e alcoholic ultimately
80 holds the power to disseminate his own disease; a fact which challenges its righteous designation as disease. gamma alcoholism begins to drink, he or she is un able to stop until poor health or terminated, however, the person is able to abstain from alcohol for varying lengths of time (DSM III ). In this quote, the DSM is referencing o 2 depreciating factors for alcoholism. A depletion of financial resources prevents the would prevent its consumptions on the basis that it could be fatal. Although it is not said explicitly, both of these factors are still indirectly tied to volition the drinker in the aforementioned situations may not have the desire or willpower to quit d rinking on his own, but depleted financial resources and a threat of fatality (upon continued drinking) provide a form of coerced volition. These are not internal biological adaptations or intervening biological cures, although the disease model of alcoho sustainable and does not function autonomously as a disease. coherent concept. While a psychological and/or chemica l dependency does not require social acknowledgment to truly exist for the sufferer, an epithet of deviance does. se cures without basis, which must be recognized as not being false cures, would 2 Jellinek only considered types of alcoholism exhibiting loss of control alcohol to be diseases. (He figured these individuals could not drink in moderation; with continued drinking, their disease was progressive.) The DSM III quote does describe alcoholism the disease.
81 soon become the true cures of false illnesses. Madness was not what one believed, nor what it believed itself to be; it was infinitely less than itself: a combination of pers uasion and mystification ( Foucault 1961: 449 ). Jellinek himself, as the father of the disease model of alcoholism, has admitted a disease is whatever the medical profession chooses to define for itself (McNeece and DiNitto 1998:4). Fingarette builds on assertion: fact alone alc oholism becomes an illness, whether a part of the lay public likes it or not, and even if a minority of the med profession is disinclined t o ac 1990: 14) In the transitions in popular terminology from di p s omania, inebriety, and alcoholism, there was no necessary change in the addiction condition itself, as the shuffling of terms and updated meanings may have implied. Alcoholism has been discerned differently in society based on cultural events, but the act ual pathological epidemiology of alcohol addiction is not marked by the changes in terminol ogy or social categorization. However t he epidemiology of addiction as a mythici zed, social disease is Addiction itself is not subjective or relative it is a real condition for those experiencing it. Addiction, like any disease, can be understood from a approach. Removed from its objective and scientific realities, how ever, addiction as a mythicized social disease must be evaluated as a cultural phenomenon Its contradicting definitions and terminologies are a testament to the non absolute and culturall y relative c ontingencies upon which a societal definit in the absence of
82 provable scientific knowledge and with the inclusion of social and economic political agendas Civic definitions of addiction, in many ways, become self fulfi lling prophecies. v Disease Theory as Self Fulfilling Prophecy The DSM IV TR:305.00 lists things which are outside the realm of acceptable sically hazardous circumstances, such as driving while drunk. An inclination to place oneself in physically hazardous circumstances is a matter of volition, and by including it in diagnostic criteria of alcoholism, t ransforms it into a symptom. Including an iss ue of volition as a symptom is inconsistent because the individual chooses whether or not to he or she will place his her her self in that hazardous circumstance, and in doing so also can choose whether they will be dia gnosable for DSM IV TR condition 305.00 Legal difficulties (another factor in the DSM diagnosis of alcoholism) was a tautological, self fulfilling argument before Robinson v California was repealed and individuals could in fact be found guilty for their mere status of being addicted. though addiction (to alcohol or otherwise) could no longer be punishable as crime, states could compel addicts to undergo treatment for th eir illness. Along the same vein a crime became (defended as) a dise ase, punishment now turned into unquestioned practice of involuntary commitment of the mentally ill, as well as the public
83 health practice of isolating and quarantining persons afflicted with serious, highly T he disease concept added to the notion of the criminal addict an element of sickness, in what Brotman defines as the criminal sick hypothesis (Brotman 1969:371) The cycle of the c riminal sick hypothes is begins with drug abuse being legislatively defined as a crime upon the origins as a medical problem. The addict then faced further difficulties from the criminal stigma. I disaffiliation from or dissatisfaction with his society, then so of drug use and stigmatization of the drug user can only serve to exacerbate the problem. Both definitions, criminal and sick, fail to consider the role played by environmental factors which have themselves contributed to the seriousn ess of the problem. Thus the current trend toward viewing drug abuse strictly as a sickness of the affected individuals may continue to divert attention from diagnosis and treatment of the contributory community fact ors (Brotman 1969: 374). The community mental health approach views the problem as an interaction between the individual the drug, and the environment (Brotman 1969: 377). This, I argue, is where medical and cultural anthropology can step in. A disease concept of alcoholism can be useful an d applicable in plenty of ways 3 But an anthropological perspective upon the disease model can enhance the validity of such a concept by studying such interactions in terms of cultural pressures, which have acted functionally to produce the states of alcoho lism which are seen today It may be argued that the tautological fashion, the disease cannot exist (since there is not medical proof otherwise) without the metaphor. 3 The modern disease theory of a lcoholism does state, after all, that problem drinking is sometimes caused by disease of the brain, characterized by altered brain structure and function.
84 vi Conclusion I known socially is left to devices apart from science. The not ion, according to Wilshire 4 is that a lack of a magical cure meant treatment professionals ought to then default to lengthy and complex institutional treatment for addicts, in the hope that a cure will at some point surface due to strenuous medical involvement of the addict and his addiction. absence of medical knowledge include bias, political agendas, and social threat. Stigma surrounding addiction can be used as leverage against pre marginalized people, or at least the consequences of the addiction stigma are most severely manife sted towards marginalized people In attempting to explain addiction in the like context of universal primal needs, the addiction, in theory, may become less alienating o f a concept to those non addicts who are seeking to comprehend addiction within their own limited, inexperienced ontologies. On th e one hand anthropol ogical approaches can comple ment medical diagnosis, as both may attempt to explain patterns Dwight Heath even says : from and are expressed in the actions and emotions of specific individuals, but our focus is less on personal uni queness than on regularities. M ost individuals within a given population share emotional and behavioral patterns to a significant degree, even when they differ from and often even contradict those that are shared by members of another population. We recognize, too, the idiosyncratic ph ysiology of each human being, and the fact that his or her life experiences are, in som e 2). 4 In the context of his critique of Schuckit in Chapter II:x, pg 41
85 One need not reject the concept of individual, physiologic uniqueness to still acknowledge and analytically value regularities. A disease concept also uses universals for its construction, and yet these unive rsals must be investigated within an individual, as xamine those ways in which members of one society not only share their experiences but also their expectations, shaped in large part by a world view that differs from that held by members o 2). In anthropology, and in the a pproach Heath takes here, the regularities referred to have boundaries. These boundaries are cultural. Regularities are not applicable cross culturally (although they can be), and they are often used for comparative purposes in anthropological study. Dr inking customs can be depicted in terms of cultural patterns of regularity within and even among cultural groups. A disease concept, however, internalizes the act of drinking. Thus the regularities it seeks to package in an siological regularities, which do not properly reflect the principle of being objective. Wilshire firmly believes in the importanc e of interweaving disciplines. Our understandings of culture, cultural phenomena, and people can be more wholly understood within an inquisitive interdisciplinary community ( Wilshire 1998: 229). Other advocative institutions exist for the studies of various types of addictions, which ad diction expert Nora Volkow feels artificial division with many missed She supports a merger of research. This source begins out on) changing the trends of alcohol abuse (Zuger 2011, D1).
86 Eventually, this thesis seeks to challenge the pragmatic practicality of the disease model of addiction by pointing out how it is both culturally constructed and culturally challenged The ultima te argument about the disease model of alcoholism is that it is Additionally, it is presumptuous in portraying alcoholism as a pathological process since there is no scientific proof that alcoholism is genetic or biological, as it would need to be in order to properly be considered a disease. The disease model inaccurately asserts a metaphor linking the developing and physically consequential habit of excessive alc ohol consumption with a pathological process. If alcoholism is a disease, it must have an etiological process that can stand alone objectively and medically. constructed) depends on culturally rela tive factors such as deviance from evolved since the disease concept of alcoholism was established, as seen from the works of early physicians 5 and in (frequently) updated editions of medical diagnostic manuals. 6 new or corrected scientific discoveries regarding the disease. However, changes in the etiology of alcoholism have been influenced by changing tides in cultural attitudes tow ards drinking and is therefore structurally unsturdy and relative, and in these ways the disease theory of alcoholism is incongruous as a medical metaphor. Yet the concept of alcoholism being an inherent, pathological flaw is further stigmatizing (and ina ccurate) accommodate, but for any individual. Once the condition of excessive alcohol 5 Such as Benjamin Rush, Thomas Trotter, E.M. Jellinek, and Charles Durfee 6 Such as the ICD (WHO) and DSM (APA) manuals
87 consumption is accepted as a chronic pathological disease, it compromises the identity o f the individual by turning his habit into an inescapable and inevitable (and also most likely a costly ) intrinsic defect.
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